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Vol 3 No 1 February 2011 




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OPERATIONAL MEDICINE 


CONTENTS 

Foreword 4 

Col TJ. Ligthelm (Guest Editor) 

Operational Military Health Support Philosophy 8 

Col W.J. Nieuwoudt, Col T.J. Ligthelm 

Challenges in Estimating Battlefield Casualties 28 

Lt Col F.F. Chamberlain 

Triage in the Combat Scenario as a Tool for the Optimal 39 
Treatment and Evacuation of the Wounded Soldier 

Maj (Res) R.C. Grobler, Maj P.J. van Aswegen 

Airway Management in the Military Environment 56 

Lt Col (Res) A. Groenewald 

Basic Mechanical Ventilation in the Operational Theatre 74 

Maj P.J. van Aswegen 

Haemostatic Technologies to Control Bleeding on the 84 
Battlefield 

Col H.J.C. Du Plessis 

Vehicle Extrication on the Battlefield 97 

Col T.J. Ligthelm, Lt Col R. McQueen, Maj P.J. van Aswegen, Maj H.S. 

Havenga, Capt A. Motilal 


3 

Health Care Management of Radiation Casualties 123 

Col B.P. Steyn 

Management Post-Traumatic Stress on the Battlefield 

Brig Gen J.A. Jansen 

Continuous Professional Development Questionnaires 1 38 

CPD Points General 
CPD Points Ethics 


EDITORIAL ASSISTANT 

Maj P.J. van Aswegen 

The Guests editor wants to express his sincere appreciation to Maj P.J. van Aswegen for the 
technical management of the Journal's articles. 


Milmed Scientific is a peer reviewed scientific journal focussed at military medicine in 

Southern Africa. 

To enhance military medicine Milmed Scientific do not retain copyright on published material 
and authors may publish the same work in another accredited journal. 

Material may however not be reproduced in any format without the written consent of the 

author. 




MILMED Scientific 
Operational Medicine 


FOREWORD 


Col TJ. Ligthelm (Guest Editor) 

SSO Strategy and Plan 
Office of the Surgeon General 
South African Military Health Service 


The battlefield entails fighting, wounding and killing one another, using the most 
advanced weapons technology and the best training available to the belligerents! 

This action is countered by one’s own forces using best technology, advanced 
weapon systems and training to try to prevent supremacy by the enemy. One of the 
weapons available to one’s own forces is operational medicine. Operational 
Medicine should therefore also entail the use of the most advanced technology and 
resources available to save as many lives as possible, with operational medical staff 
as battle winners through competent pre-hospital care, in-transit care during tactical 
evacuation, in care in deployed and base hospitals and aeromedical evacuation (1). 

Operational medicine should not only include saving lives, but also saving limbs and 
eyesight through a seamless system of force health protection, force health 
sustainment and force health improvement from point of wounding to rehabilitation 
through coordinated clinical approaches. 

To achieve this, operational medicine, similar to the weapons used to counter the 
enemy, should be advanced, include cutting edge scientifically-based technology, 
and should be practiced by skilled personnel. It should be timeously available, 
mobile, flexible, economical in effort and sustained. 

The purpose of operational medicine remains the countering of the enemy’s 
weapon’s impact on the human body through appropriate interventions. Today, as in 


years past, non-compressible haemorrhage and junctional trauma remain the main 
killers on the battlefield (1) and measures should focus on addressing these issues. 
The best counteraction to bleeding is still to stop the bleeding! For this purpose, 
various interventions are available: 

• Skilled early emergency care interventions to sustain physiological functions 

(2); 

• Control bleeding through external actions (mainly aimed at the compressible 
bleeding) such as the liberal use of tourniquets and haemostatic dressings; 

• Damage control surgery and damage control resuscitation techniques (3); 

• Skilled and competent human resources. 

Unfortunately, very few of these interventions are presently readily available in the 
African Battle Space and in the SAMHS arsenal. 

The availability of early emergency care interventions is pivotal to delivering a 
salvageable casualty to the military surgeon both in the field and at base. These 
include rapid catastrophic bleeding control, definitive airway interventions and 
maintenance of fluid balance, taking cognisance of hypovolemic fluid resuscitation 
principles. Unfortunately, we are presently lacking these weapons with the SAMHS 
yet to introduce battlefield tourniquets or haemostatic dressings into the soldier 
packs, and making advance infusion equipment available to the field medic. 

In Operational Medicine, time is of the essence, which is why battlefield vehicle 
extrication and effective decontamination are such critical interventions. The longer 
we take to provide this the lower the chances of survival (3) . Rapid, effective 
evacuation, with in-transit care, to appropriate care is critical (4). The use of 
consultant led helicopter primary retrieval teams has proved to be essential in the 
survival chain in the present international conflict theatres (1) . 

We should also investigate the concepts of our evacuation lines. Is there still a role 
for the pure Level 1 Resuscitation Capability (Role 2) in managing trauma? 
Currently, the model of advanced life support at point of injury and rapid helicopter 
evacuation to Level 2 Field Hospital (Role 3) capabilities is achieving the best 
survival ever in combat (1)! This is the main reason why the SAMHS moved from a 
single resuscitation approach at its Level 1 capability (3)(hyperlink \i "Sou08" 3), to an 



integrated resuscitation and surgical concept, however, the weapon system to 
provide this is absent. 

Timeliness remains one of the tactical yardsticks for providing operational health 
care. The timeline from wounding to surgical care remains one of the most 
challenging factors for the SAMHS. In Operation Iraqi Freedom, an increase in the 
timeline from 30 to 59 min between wounding and surgical intervention, resulted in 
an increase of 13,5% to 20,2% for those killed in action, but, more alarmingly, an 
increase from 0,8% to 5,5% in casualties who died of wounds (2). The American 
Special Forces classified 15% of those killed as potentially salvageable with 
adequate surgical intervention. Tai et al concluded that an absolute upper limit for 
formal commencement of damage control surgery is 120 min from wounding (4). 
This is the foundation of the SAMHS 1 :2:4 doctrinal principles). This requires that the 
SAMHS urgently addresses the deployable surgical capabilities in its arsenal - 
including damage control surgical capabilities and appropriately skilled manpower as 
far forward as possible. 

We should learn from the present trauma experience in worldwide combat areas, 
where massive transfusion protocols are required (with blood unavailable in our 
deployments), deployed radiologist with capabilities has proven essential (FAST 
capabilities) and specialised nurses in deployed roles are used to provide required 
levels of care (1). 

Irrespective of the weapons that may be available to operational medicine, the skilled 
human resource is, and remains, the warrior who will use these. This requires a very 
careful approach. The UK medical service emerged from the cold war over staffed, 
declaring components of their service and human resources redundant and reducing 
their manpower, only to experience critical shortages in human resources a scant 
four years laterl). Civilian medicine remains the basis for clinical training between 
deployments and is the foundation for attracting appropriately skilled, motivated and 
committed civilian clinicians to serve in the Reserves. The proposals for Emergency 
Centres at military hospitals to breed these for battlefield utilisation will most certainly 
improve our capabilities. 

Mental health capabilities are an integral part of the operational medicine arsenal 
and also require timely intervention to ensure survivability. 



Reducing disease and non-battle injuries remains just as important. This includes 
comprehensive force health protection measures such as ensuring that adequate 
eye protection is provided and worn by all. 

The Military Health Service should ensure that it counters the enemy’s high 
technology weapon systems with similar if not better medical weapons to ensure 
optimal survivability of the wounded. This issue of MILMED Scientific aims at 
stimulating interest in operational medicine, not only inviting comment, but also 
providing advice on critical interventions that may be of value to counter enemy 
actions. 

REFERENCES 

(1) Liilywhite LP. Thervices. Journal of the Royal Army Medical Corps. 2009 Dec; 155(5). 

(2) Edens JW, Beekley AC, al e. Combat Casualty ED Toracotomy. J American Col Surgeons. 2009 
August; 209. 

(3) Fox CJ, Gillispie DL, al e. Damage Control Resussitation for Vascular Trauma in a Combat Support 
Hospital. J Trauma. 2008 July; 65(1). 

(4) Tai N, Brooks A, Midwinter M, Clasper JC, Parker PJ. Optimal Clinical Timelines - A Consensus 
From The Academic Department of Military Surgery and Trauma. Journal of the Royal Army 
Medical Corps. 2009 Dec; 155(4). 

(5) Chung KK, Blackbourne LH, al e. Global Evacuation of Burns Patients. J Trauma. 2008 July; 65(1). 

(6) South African Military Health Service. Operational Doctrine Pretoria: SAHMS; 2008. 



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OPERATIONAL MILITARY HEALTH SUPPORT 
PHILOSOPHY: A SOUTH AFRICAN PERSPECTIVE 


Col W.J. Nieuwoudt, sm, mmm, s stj, jcs 

BPA (Hon); B Mil 
Chief of Staff 

Military Health Training Formation 
South African Military Health Service 


Col T.J. Ligthelm, mmm, c stj 

MPA, B Soc Sc (Hon), H Dip Ed, Dip Adv Nurs 
SSO Doctrine and Plan 
Office of the Surgeon General 
South African Military Health Service 

ABSTRACT 


Human resources can be considered the most valuable resource of any 
military force. Health support is a key element in sustaining the physical, 
mental and social well-being of this resource and therefore vital to the success 
of operational readiness. Operational Health Support uses wartime and 
peacetime missions to direct the peacetime force preparation strategy and 
force employment for incidences of conflict. 

Operational Health Support addresses the human battle space of a total 
onslaught against the human body, mind and relationships, rendering the 
individual incapable of effectively operating the weapon systems designed to 
win the land, air or maritime battles. 

Within any battle scenario, it is important to analyse, through an appreciation, 
the enemy and its tactics, and to define the most appropriate composition of 
own forces, the operational battle design, the resources needed and the 
theatre of war. 



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Operational health support takes the responsibility for the casualty from point 
of injury until discharge or death, including the rendering of forensic services 
on the battlefield. This is delivered through a building block approach of 
stepped-up care to deliver a holistic health support system adhering to clinical 
and ethical principles. 


INTRODUCTION 

Human resources can be considered the most valuable resource of any military 
force. Health support is a key element in sustaining the physical, mental and social 
well-being of this resource and therefore vital to the success of operational 
readiness. A military health service organises, trains and equips to provide a health- 
ready fighting force capable of executing successful military operations. Together, a 
ready military health service and healthy, fit fighting forces ensure mission 
responsiveness. 

MILITARY STRATEGY IMPERATIVES 

The military strategy provides the answer to the military challenges that can be 
expected by the country in the future (1). The Employ Forces Strategy (which 
include the Force Employment Strategy, the Joint Force Preparation Strategy and 
the Multi-national Force Preparation Strategy), the Prepare Forces Strategy 
(including the Force Structure Strategy and the Force Preparation Strategy with 
ends, ways and means to prepare Combat Ready Higher Order User Systems), the 
Provide Forces Strategy (including the Acquisition and Research & Development 
Projects) and the Support Strategies further support the military strategy of the 
Republic of South Africa. These strategies shape the provision of operational 
military health support by the Military Health Service. 

The Military Strategy identifies three military strategic objectives. These are to 
enhance and maintain comprehensive defence capabilities, to promote peace, 



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security and stability in the region and on the continent and to support the people of 
South Africa. 


• To Enhance and Maintain Comprehensive Defence Capabilities . The 
approach to this military strategic objective is based on alliance and/or 
coalition warfare and multinational force employment. The Defence Force 
will, in cooperation with the neighbouring states, have a strategic 
defensive posture whilst maintaining sufficiently tailored operational and 
tactical offensive capabilities in order to deter potential threats. The 
concept of selective engagement will be applied to determine the Defence 
Force’s scope and level of employment while early warning will be 
achieved through strategic positioning. The mission-trained force 
(multinational) will execute the operation. Special operations and activities 
can be utilised to protect foreign assets. 

• To Promote Peace, Security and Stability in the Region and on the 
Continent . The promotion of peace, security and stability entails reaching 
out to Africa through the establishment of mutual trust and interests, 
acceptance of the concept of collective responsibility, multinational force 
preparation and planning, and the exchange of training teams, students 
and staff officers, information and technology to set the scene for a stable 
region. The RSA, as part of a multinational force and with support from 
the international community, will prepare itself for involvement in peace 
enforcement and/or intervention operations in order to protect regional 
interests. 

• Supporting the People of South Africa . This military strategic objective 
entails supporting the population of South Africa by means of operations 
other than war during periods when the responsible state departments do 
not have the capacity to do so. The inherent capabilities of the Defence 
Force will be utilised to support other state departments in the execution 
of required tasks/operations. The concept of selective engagement will 
determine the level of involvement. 


The way in which the Defence Force will achieve these three strategic objectives is 




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through a mission-based approach. This approach uses wartime and peacetime 
missions to direct the peacetime force preparation strategy and force employment for 
incidences of conflict. The following are two important concepts of the mission-based 
approach that will guide operational military health support: 

• Selective Engagement . The concept of selective engagement indicates 
that the Defence Force will execute all the prescribed missions, but will be 
selective in terms of the extent to which operations and tasks emanating 
from these missions will be executed. This concept implies that calculated 
risks will have to be taken. 

• Strategic Positioning . This concept indicates that the Defence Force is 
willing to proactively establish a sound security environment, supported by 
influencing political and military foreign relations actions, and the pre- 
placement of appropriate military capabilities. 

The Military Strategy identifies the means to achieve these military strategic 
objectives as the following: 

• Light Mobile Capability . Personnel and materiel must be prepared and 
sustained to participate in operations where agility, flexibility and limited 
firepower are required. 

• Conventional Warfare Capability . Personnel, materiel and doctrine 
prepared and sustained to repel a conventional onslaught. 

• Support Capability . The ability to support and sustain systems 
commensurate with the force and executing the mission according to the 
military strategic objectives ensuring strategic reach. 

• C 4 I 3 RS . This is a collective description consisting of the elements of 
command and control, communications, computers, information, 
intelligence, infrastructure, reconnaissance and surveillance. It is the 
essential military sensory capability and command and control support for 
the whole range of military missions. 


The Military Strategy guides the Military Health Service to be prepared to provide 



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operational military health support over the full spectrum of missions from 
conventional warfare to support to the people. This support must be flexible, agile 
and sustained and must be able to function in a multinational force environment and 
fit in with the C 4 I 3 RS capability of the supported force. 

In multinational operations, specific national contingents may have a framework 
responsibility for the coordination of particular combat service support functions, or 
the provision of specific services or commodities for the whole force. It is thus 
essential that systems, units or forces be able to provide services to and accept 
services from other systems, units and forces and to use the services so exchanged 
in order to operate effectively together. 

International law requires all casualties to be treated according to clinical priority 
regardless of origin. The medical plan will inevitably have a combined aspect as 
national contingents may provide different specialist medical capabilities or specific 
medical units. Casevac resources should always be integrated into a unified plan. 

GENERAL APPROACH TO OPERATIONAL MILITARY HEALTH 
SUPPORT 

This approach provides overall guidance to provide operational military health 
support and should be applied when planning military health support to any type of 
operation. 

A Holistic Approach to Health 

The enjoyment of the highest attainable standard of health is one of the fundamental 
rights of every human being. Health is a state of complete physical, mental and 
social well-being and not merely the absence of disease or infirmity (2). In the 
military context, health may be defined as the ability of military personnel to function 
unimpeded by physical, psychological or social problems. In order to maintain and 
promote health, one should aim to alter the determinants. The health of a soldier is 
determined by a variety of factors, such as genetic, social, economic, environmental, 
lifestyle and operational factors, as well as access to health services. Due to the 



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nature of the military, soldiers are deliberately placed in danger with the knowledge 
that some are likely to succumb to disease, be injured or killed, or be subjected to 
circumstances that lead to family disruption. Although the Military Health Service is 
the primary military health care provider of the Defence Force, it is not solely 
responsible for ensuring a healthy soldier. 

Responsibilities for Health 

There are three broad areas of responsibility for health within the military: individuals, 
the chain of command and the Military Health Service. 

• Individuals . Lifestyle and behaviour are a powerful influence on health. 
Military personnel therefore have considerable responsibility for their own 
health, which includes following preventative advice. All personnel should 
acknowledge these responsibilities and take them seriously. Personnel 
will require leadership, education and positive role models, particularly 
commanders, in order to increase awareness and individual responsibility. 

• Chain of Command . The chain of command has control over a number of 
the determinants of health through its ability to influence occupational 
issues. The health of the military population should be an integral part of 
any human resources strategy, with measures to promote and maintain 
health enshrined in policy. 

• The Military Health Service . The Military Health Service has two distinct 
areas of responsibility in contributing to military health: the provision of 
advice to the chain of command on the promotion of health, and the 
delivery of high-quality, timely health care capabilities in peace and war. 
Both make a valuable contribution to force protection. To ensure a healthy 
soldier, the Military Health Service applies a multidisciplinary approach 
that addresses the physical, psychological and social well-being of the 
soldier and his/her family. 

The Human Battle Space 

Within the land battle space, the air battle space and the maritime battle space it is of 
utmost importance for a soldier to focus on the task at hand. The enemy must not 



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only be out-fought but must also be out-thought. Cognitive dominance will be one of 
the most important attributes of the modern soldier to win the war and not only the 
battle. The relationship between a healthy body and a healthy mind is well known 
and therefore the military health service must strive to ensure optimal physical health 
as well as optimal mental health towards combat readiness. 

It is true that we do not live in a perfect world and therefore there are a multitude of 
“enemies” with a total onslaught against the human body, mind and relationships, 
rendering the individual incapable of effectively operating the weapon systems 
designed to win the land, air or maritime battles in protecting the sovereignty of our 
country. Within this “human battle space”, the enemy is as fierce and cunning as one 
would find in any other battle. The weapon systems to be employed are very 
sophisticated and can be very effective if optimally utilised. The battles are fought 
within the ecosystem we inhabit, within our population and society, within our 
immediate environment and within our own bodies. 

Within the human battle space, the enemy has been identified as 


• pathogenic organisms and their vectors; 

• dangerous substances and the abuse thereof; 

• uncontrolled and/or deliberate physical force. This includes the enemy 
threat leading to combat situations; 

• harsh climatic conditions and other environmental hazards; 

• diseases of life-style (the so-called non-communicable diseases); and 

• malicious human behaviour and mental health. 


Within the human battle space, the own forces have been identified as 


• health care providers; 

• stock and equipment; 

• infrastructure; 

• command and control; 

• management information; 





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• support elements such as health intelligence, epidemiology and security; 
and 

• appropriate research and development. 


Within any battle scenario, it is important to analyse, through an appreciation, the 
enemy and its tactics, and to define the most appropriate composition of own forces, 
the operational battle design, the resources needed and the theatre of war. An 
appropriate plan must then be executed with dedication and determination. The 
human battlefield is superimposed onto every other battlefield and it can be stated 
categorically that, if the battles within the human battlefield are lost, the war will be 
lost. 

Force Health Protection 

Force health protection (FHP) is the military health strategy to support the military 
strategy. It starts at home and continues during every deployment scenario not only 
to ensure combat-ready forces, but also to ensure optimal operational health care 
support. The military force must have a robust resilience against the “enemy within 
the human battlefield. Healthy and fit members are less likely to be injured, can 
withstand diseases and battle stress, and will heal much more quickly from wounds 
and other diseases. 

Protection is built upon a strong partnership through the overarching partner process 
of Force Health Improvement, including a partnership between military and civilian 
health care professionals, line leadership and beneficiaries. It constitutes a cycle of 
assessment (continuous health surveillance), intervention (medical and other health- 
related interventions, disease and casualty prevention) and enhancement (health 
promotion). 

Force Health Protection and Improvement include the following elements: 

• Prevention activities like immunisations and vector control. 

• Promotion activities like education and awareness. 

• Occupational Health and Safety. 

• Physical Training, Sport and Recreation. 




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• A healthy diet. 

• Workplace programmes. 

• Community health, including the following: 

• Food security. 

• Clean water. 

• Sanitation. 

• Environmental health. 

• Waste management. 

• Ecosystem interaction and preservation. 

• Epidemiology and health intelligence. 

• Health assessments. 

• Risk management. 

Operational Military Health Support 

Operational Health Support is an integral part of the Force Health Protection process 
and is supported by Force Health Improvement measures. 

The operational military health plan must provide for preventative, promotional, 
diagnostics, curative, rehabilitative, palliative care and a research & development 
approach during every operation regardless of the size, location and type of force or 
operation. This does not necessarily imply the physical deployment of elements to 
provide all these services in the theatre of operations. It implies that the process of 
ensuring health starts before a soldier becomes a casualty and continues until he or 
she exits from the system. Preventative programmes must be in place before, during 
and on completion of an operation to minimise casualties (both battle casualties and 
disease and non-battle injuries). 

The operational health support takes the responsibility for the casualty from point of 
injury until discharge or death, including the rendering of forensic services on the 
battlefield. 

The fact that deployments may be in remote areas should not have an effect on the 
quality of health care provided to the deployed soldier. Deployed members of a 



10 


Defence Force should, as a matter of principle, have the same quality of health care 
(or better) than what he/she would have received at the home base. The Military 
Health Service remains accountable for the provision of health support to members 
of the Defence Force and therefore will, as far as possible, plan to provide health 
support to own troops during Multi-National operations. In cases where this is not 
possible, planners should evaluate other nation support to ensure that the quality of 
service that is available is of an acceptable standard. 

THE MISSION-TAILORED BUILDING BLOCK APPROACH 

The size, duration and nature of deployments cannot be determined in advance. 
National security requirements may call for involvement in activities ranging from a 
major regional conflict to small, tailored health care teams operating in remote, very 
primitive conditions. Any deployment can grow (or shrink) within these upper and 
lower extremes. 

Military health support must be flexible and modular and must anticipate changes in 
deployment requirements. The approach is to group a combination of operational 
military health building blocks according to the unique requirements of each mission. 
Each building block is designed as a specific functional capability (User System) to 
contribute to the holistic approach to military health support and can operate as an 
entity or as part of a bigger grouping. 



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Combat Zone 

Inherent : Operational Health 


Communication 


Base Zone 


Landward Defence 


Emergency Care 
Section 


^ Land Based 
Combat Life Saver Emergency Care 


Buddy Aid 


Air Crash 
Response Team 


Level 1 Forensic 


Emergency Care 


Section 


Level 1 Capability 
Land Mobile 
Level 1 Capability |j 1 
Air Landed 

Level 1 Capability IE H 
Sea Landed 

Level 1 Capability |L1 
Air Droppable 


Zone 


Level 2 
Field Hospital 


Level 2 Forensic 


Buddy Aid 


Maritime Defence 


Land Based 
Emergency Care 


Combat Life Saver 


Level 1 Forensic 


Temporary 

Ship/Boat 

Capability 


Level 1 

Ship Capability 


Shore Capability 


Maritime 
First Aid 


Special Forces 


Operator Care / 
PHTLS 


Maritime 
Emergency Care 

Air Borne 
Emergency Care 


Level 2 

Casualty Receiving 
Ship 


Buddy Aid 


Base Orientated Service 


Level 1 Capability 
Air Droppable 


Poly Clinic 


Level 2 
Field Hospital 


In Theatre 


Level 3 

Specialist Hosp 



Military Hospital 


Prov Health 
Facility 


RSA 


Level 4 
Base Hospital 



Dept of Health 
Forensic 
Capability 


Prov Health 
Facility 

© Col T. Ligthelm 


Figure 1 : Stepped-Up Health Support Concept 


The 1 :2:4 Principle 

In saving life, limb and organ (specifically vision), time is of the essence. It is 
essential that the “save life initiative” starts immediately after injury/illness. The 
grouping of casualties with the potential to benefit from medical intervention is the 
greatest in the first 30 minutes after wounding. 94% (ninety four percent) of deaths 
occur within the first two hours after injury (1). The longer the time-lapse between 
injury and surgery, the lesser the chance of success. 

The approach should be to shorten the interval from injury to initial care, reducing the 
evacuation time to an appropriately capable health care facility for controlling 
catastrophic bleeding and managing the airway, breathing and circulation. This may 
often be achieved by bringing the care forward, rather than evacuating the casualty 
to the care. Time is therefore the guiding factor in determining where what capability 










12 


of support should be, while the number and type of casualties will determine the size 
and shape of each military health support capability. 

The guiding rules to apply during the planning of operational military health support 
are as follows: 


• Rapid access to first aid with battlefield advanced trauma life support 
standards of care within one hour of wounding. 

• Access to surgical resuscitation (damage control surgery) for those who 
require it within two hours of injury. 

• Definitive surgery within four hours of injury. 


The Step-Up Approach 

The Military Health Service subscribes to a step-up approach with the deployment of 
military health services based on the emergency care management capability of the 
military health support elements. Operational health support consists of six capability 
levels grouped in four lines of support The treatment capability of each level is 
intrinsic to the higher level, eg an advanced care facility will have the ability to carry 
out intermediate care functions. There is no requirement that a patient must 
necessarily pass through each echelon of care in progression during treatment and 
evacuation. 

Operational Health Support Capability Levels 


• First Responder . This comprises the buddy aid and combat-lifesaver 
capability and provides a lifesaving initiative by trained non-medical fellow 
soldiers from the combat element. This capability will be intrinsic to every 
operational element on section/team level. 

• Emergency Care . This capability provides battlefield advanced 
resuscitation, stabilisation, evacuation of casualties and first line primary 
health care (treatment of minor ailments only) by trained operational 
emergency care personnel (OECPs and ECTs). It should be deployed 
with every operational deployment where the risk of casualties is medium 




13 


or higher and medical infrastructure is further than 10-30 minutes away. 

• Intermediate Care . This is the first level where a medical officer and/or 
paramedic is available and provides an advanced trauma lifesaving 
capability, stabilisation, primary and secondary health care and 
evacuation to the next level. It should be deployed in situations further 
than 10-60 minutes from surgical infrastructure where the risk of 
casualties is high. 

• Advanced Care . This capability provides emergency resuscitation and 
stabilisation, damage control surgery, second line health care, basic 
dental care, operational stress management, social work interventions, 
casualty evacuation to the next level and a preventative health service. 
This level of advanced support is normally deployed in cases where the 
appropriate level of care is not available within 2 hours after injury. If the 
situation requires, advanced care elements may be deployed forward with 
first line military health facilities. 

• Specialised Care . This level includes specialist diagnostic resources, 
specialist surgical and medical capabilities, preventive medicine, ancillary 
health services, dentistry, psychology and social work. The holding 
capacity should be sufficient to allow diagnosis and inpatient treatment of 
those patients who can receive total treatment and be returned to duty 
within the evacuation policy laid down by the medical commander for the 
theatre of operations. 

• Definitive Care . This level of care is usually highly specialised and time 
consuming. It would normally comprise specialist surgical and medical 
procedures, reconstruction, rehabilitation, convalescence, and 
psychological and social support. This capability provides definitive care 
of patients for whom the treatment required is longer than the theatre 
evacuation policy or for whom the capabilities usually found in the theatre 
of operations are inadequate. This level of care is provided by the military 
hospitals or a combination of military/provincial/private facilities in the 
RSA. 


Lines of Operational Health Support . Lines of operational military health support are 



14 


identified in accordance with the echelon system and should not be confused with 
the levels of care. The lines of health support indicate the command level that 
controls the deployment. 


• First Line Support . This line of support is found at the combat or combat 
support unit level and is responsible for the immediate support to such a 
unit. It includes the unit’s integral first aid capability as well as the 
attached intermediate and/or emergency care capabilities. 

• Second Line Support . This line of support consists of the advanced care 
capability and forms the second line of support for cases whose treatment 
requirement exceeds that of the first line capability. This level of care is 
normally controlled by the formation medical commander and is 
considered a formation asset. 

• Third Line Support . The specialist care capability is the third line of 
operational military health support. It is normally deployed in situations 
where it is not possible to evacuate casualties requiring specialist 
diagnostic, surgical or medical services within the acceptable time 
restrictions to a suitable existing facility. It may also be deployed in 
situations where it will be more cost-effective to deploy a specialist 
capability to the theatre of operations than to evacuate casualties back to 
the military hospitals. The command affiliation of a third line military health 
facility will always be to the highest headquarters in the theatre of 
operations. 

• Fourth Line Support (Home Base Support) . This constitutes all those 
military and civilian health facilities permanently positioned in the RSA. It 
provides definitive care to those casualties who cannot be returned to duty 
within the theatre evacuation policy or who require treatment outside the 
capability of the in-theatre military health facilities. 


PRINCIPLES OF OPERATIONAL MILITARY HEALTH SUPPORT 

Timeliness 

Timeliness concerns the provision of an in-time operational health support system 



15 


that provides appropriate health care at the right place with the right capability to 
ensure preservation of quality of life. This requires early warning and 
joint/multinational operational planning at all levels. Operational health care must 
ensure a timely step-up support system that adheres to the clinical principles to 
ensure preservation of quality of life. Health care facilities are located as far forward 
as possible; however, they must not be positioned so far forward as to interfere with 
combat operations or be subjected to enemy harassment. 

Mobility 

Mobility implies the ability to project operational health support capabilities by land, 
air and sea. This includes strategic, operational and tactical mobility. First line health 
care elements must maintain close contact with the manoeuvring combat elements 
they support. Therefore, they must have transportation (including evacuation 
capabilities) compatible with the combat units they support. 

Flexibility 

Flexibility involves the ability to adapt operational health support based on a detailed 
health appreciation in order to meet the health care requirements of a mission. The 
principle should be to deploy the appropriate health user systems and build them up 
according to a step-up approach. 

Economy of Effort 

Economy of effort concerns the concentration of available resources to provide a 
mission-orientated multidisciplinary capability to achieve optimal operational health 
care. This is achieved through a step-up building-block approach. 

Multidisciplinary Approach 

This approach implies the mission-driven utilisation of applicable elements of the 
multidisciplinary team as far forward as necessary within their scope of practice to 
ensure optimal operational health care. 

Patient Safety and Security 

Operational health support ensures optimal safety and security to the patient and 
his/her physical integrity and dignity. This is achieved through appropriate safety 



16 


measures, protection, professionalism and medical confidentiality and includes 
adherence to the Geneva Convention and Protocols, the Law on Armed Conflict, 
health ethics and statutory principles. The Military Health Service is dependant on 
the supported force to provide protection to its facilities, personnel and patients. 
Military Health Service planners should ensure that this aspect is addressed during 
planning and that the requirements are submitted to the Supported Force 
Commander in time. 

Health Intelligence 

Health intelligence is the continuous provision of a health intelligence capability that 
provides a health profile of the area of influence. This impact on the facilitation of the 
process of providing preventative health support supplemented by specific treatment 
protocols. It requires early warning and joint/multinational planning on all applicable 
levels. 

Sustainment 

An operational health support capability requires guaranteed logistical and personnel 
support that addresses the following critical aspects: 


• A joint/multinational approach, including maintenance, repair and 
replacement of equipment and vehicles. 

• Compatibility and interoperability. 

• Focused logistics (balancing just-in-time with just-in-case). 

• Personnel replacements. 

• A focus on Military Health Service-unique and shared requirements. 

• Thorough planning, constant liaison and close monitoring. 


Unity of Command 

The Military Health Service adheres to the principle of unified command. During joint 
operations, Military Health Service combat-ready force structure elements are placed 
under the operational command of the joint force commander for the duration of the 
operation. During multinational operations, Defence Force elements are placed 
under operational control of the force commander. Functional control is retained 




17 


within the Military Health Service. This implies that there will be a Military Health 
Service commander appointed for each Military Health Service force structure 
element to maintain functional control. 

Conformity 

The health service support plan must conform to the tactical plan of operations. It 
must also conform to the highest level of medical and other health-related care 
standards and ethics. 

Continuity 

Triage, treatment and evacuation must be continued until the patient reaches a 
health care facility capable of providing definitive care for his/her condition. No 
patient is evacuated further to the rear than is justified by the extent of the 
psychosocial and physical condition or warranted by the operational situation. 

MILITARY HEALTH OPERATING SYSTEMS 

Operational military health support is comprised of functional operating systems that 
provide a continuum of health care from the point of injury rearward to definitive and 
rehabilitative care in the sustaining base. It is impossible to address the total 
spectrum of systems within an article, therefore only the direct casualty care systems 
will be explained. 

Medical Treatment System 

In the forward areas of the operational area, health care personnel attached to the 
combat elements or a supporting medical element on an area support basis, provide 
first and second line medical treatment. Medical care at these levels includes 
emergency medical treatment, advanced trauma management, initial resuscitative 
surgery, life-and-limb-saving surgical interventions and routine sick reports. 

Medical Regulating and the Patient Evacuation System 

Medical regulating is the coordination and control of the movement of patients to the 
health care facility best suited to provide the required care. This function ensures the 



18 


efficient and safe movement of patients through the health care delivery system. 

Patient evacuation provides the links between the lines of care on the battlefield. It 
provides continuous medical treatment while the patient is being evacuated rearward 
to the facility best suited to care for his/her health condition. Patient evacuation is 
accomplished by the lower role evacuating to the higher role. Evacuation 
encompasses the following: 

• Collecting the wounded (which may include hot extraction of the 

wounded). 

• Performing triage (sorting). 

• Providing an evacuation mode. 

• Providing medical care en route. 

• Anticipating complications and being ready and capable to perform 
emergency medical intervention. 

• Collecting and storing the bodies of those killed 

Hospitalisation System 

A hospitalisation system comprises medical treatment building blocks capable of 
providing inpatient care. It is appropriately staffed and equipped to provide 

diagnostic and therapeutic services, as well as the necessary supporting services 
required to perform its assigned mission and functions. In addition, a hospital may 
discharge the functions of an outpatient service. 

Ancillary health disciplines form part of the hospitalisation system and have a definite 
role to play in providing operational military health support. Their support covers the 
total spectrum of care from prevention to rehabilitation. Ancillary health disciplines 
will generally not deploy lower than second line facilities. Ancillary health disciplines 
within the Military Health Service that will be deployed operationally include, but are 
not limited to, the following: 

• Radiography. 

• Physiotherapy. 

• Dietetics. 



19 


• Medical technology. 

• Biomedical technicians. 

The various levels of hospitalisation include a Level 2 Field Hospital, Level 3 
Specialist Hospital Capability (for example 2 and 3 Military Hospitals) and a Level 4 
Base Hospital Capability ( as example 1 Military Hospital). 

Other Systems 

Numerous other systems contribute to a holistic approach to operational support. 
These include a Preventative Health System to ensure a healthy soldier for 
deployment, Oral Health System addressing dental needs comprehensively and 
assisting in forensic identification of bodies, Animal Health Services addressing both 
the health of deployed animals and preventing zoonotic disease outbreaks, 
Psychological Support and Military Social Work Support ensuring mental and social 
resilience and addressing stress disorders, Military Health Forensic System 
collecting and transporting bodies including basic post-mortem investigations, 
Sustainment to enable systems to operate and ensuring projection of capabilities, 
Health Intelligence Support and a Patient Administration System ensuring accurate 
record keeping. 

All of these systems combined represent a holistic operational health support 
system. 

ETHICAL PRINCIPALS 

The rendering of operational health support is guided by ethical principals directing 
action and guiding decisions. 

The focus is to render effective operational health support to ensure that life is 
optimally preserved and health restored. Life is seen as a most valuable, 
irreplaceable status of the human being, therefore, soldiers are by International 
Standard Principles entitled to guaranteed, Operational Health Care available at all 
times. 



20 


This Operational Health Care will be delivered within ethical principals guiding the 
practitioner in his/her professional capacity. This includes that Health Care 
Practitioners will not use their medical knowledge contrary to the Laws of Humanity 
(2) (3) (4). They will deliver care for the sick and wounded without any adverse 
distinction founded on sex, race, nationality, religion, political opinion or any other 
similar criteria. Only medical urgency can justify priority in the order of treatment. In 
this role, a military health service will respect the need for emergency care to both 
own forces and other belligerents within the operational environment (2). At all times 
health care of at least the same quality that is available to own forces within the 
geographical borders of the country will be available to the deployed elements. 

CONCLUSION 


The Military Health Service Operational Support Philosophy forms the foundation for 
all operational military health support planning and guides the support to any 
operation in which soldiers may be involved. 

The result of the application of this philosophy should be coordinated, cost-effective 
and sustained health support to operations in various operational theatres. It should 
ensure that casualties are returned fighting-fit to their units in the shortest possible 
time. 


REFERENCES 

(1) South African Military Health Service. Operational Doctrine Pretoria: SAHMS; 2008. 

(2) World Health Organisation. [Online], [cited 2007 Jul 15. Available from: 
http://policy.who.int/cgi-bin/ . 

(3) International Comittee of the Red Cross. International Humanitarian Law - Treaties and 
Documents. 1949 Conventions & Additional Protocols. [Online], [cited 2009 December 
02. Available from: http://www.icrc.org/ihl.nsf/CONVPRES7QpenView . 

(4) International Commitee of the Red Cross. The Geneva Conventions of August 12 1949. 
In. Geneva: International Commitee of the Red Cross; n.d. 

(5) Baccino-Astrada A. Manual on rights and duties of medical personnel in Armed 
Conflicts. 2006.. 

(6) Vayer JS. Lessons for the future. Armed Forces Medical Developments. 2001; 2. 


21 



Challenges in Estimating Battlefield Casualties 


LtCol F.F. Chamberlain 

Directing Staff South African National War College 


ABSTRACT 


Casualty estimates is the planning tool used by military health planners to 
determine the projected number of casualties expected during a specific military 
operation in order to determine what resources are required. It allows for the 
planning and deployment of the correct systems at the correct place, making sure 
that the right type of support is at the right place at the right time. It is, however, 
just as the words describe, an estimate and planning tool and should not be seen 
as a casualty prediction. In order to achieve this, one must be able to calculate the 
appropriate variables for the specific force levels and circumstances. The casualty 
estimate is the backbone of operational health planning, and should, therefore, be 
an embedded skill in all military health practitioners, especially planners. Casualty 
Estimation Tables are at the core of health planning and determine the ultimate 
risk to human life, implications which can and will be felt on tactical, operational as 
well as strategic levels. 

The article gives an overview of the difficulty in compiling accurate and applicable 
casualty estimate tables and compares various models used by different countries. 
It highlights the problems of utilizing the present SANDF Casualty Estimate Tables 
and comes to the conclusion that the current tables are oversimplified and cannot 
address the specific needs of health planners or commanders. Not enough 
specifics and variables are available to everyone in the joint environment with little 
reference to the air component and little to no reference to the maritime 
component. 

The article does not aim to provide alternatives for the present tables. The use and 
value of casualty estimates as the basic tool for medical planners are discussed 
and the article highlights the challenges in using the various models available. The 
need for future research to compile a valid South African model is underpinned by 
the findings. 



2 


INTRODUCTION 

American Senator, John Glenn, said in 1997 that “it is easy to see. . . . People go off to 
war and the bands play and the flags fly. And it's not quite so easy when the flag is 
draped over a coffin coming back through Dover” (1). 

That is the nature of the American public's sensitivity to military casualties. There is no 
intrinsic, uncritical casualty aversion among the American public that limits the use of 
United States (U.S.) armed forces. There is a wide range of policy objectives in terms of 
which the public is prepared to accept American casualties as the cost of success. 
Squeamishness about even a few casualties for all but the most important national 
causes is a myth. Nonetheless, it is a myth that persists as widely accepted conventional 
wisdom which seems to have translated to the rest of the world as well Although a 
sensitive and emotional issue, casualties are, unfortunately, a reality of any form of 
military conflict. Determining the extent of this is most important on the operational level 
in the allocation of resources, the tactical level in the maintenance of combat efficiency 
and on the strategic level, especially for the politicians addressing strategic interests 
regarding foreign policy in sending sons and daughters of citizens to war 

Military leaders adhere to the principle of economy of force and do not want to fritter 
away limited assets on missions that might detract from the ultimate mission of defeating 
vital threats to national security. It is with this in mind that casualty estimation is done in 
the military context to determine the projected number of casualties expected during a 
specific military operation. This is done not only to determine the required personnel to 
maintain force levels, but also to determine resource allocations and especially planning 
for health care by the Military Health Service. The planner, by carefully applying medical 
doctrine and principles, will strive to provide the best possible Health Service Support 
(HSS) system for all operations. Proper planning enhances the capability of the health 
units in providing effective HSS, which is a key factor in conserving combat power of the 
supported force (2). It forms the nucleus of medical planning for any type of operation 
whether it is armed conflict or peace support type operations- anywhere where health 
support of some sort is required. 



3 


WHAT IS CASUALTY ESTIMATION? 

Casualty estimation is, as the words describe, an estimate. It is not to be seen as a 
casualty prediction. It will provide information to the commander of the operation or 
campaign allowing him/her to make an informed decision with regard to the risks 
pertaining to specific planned actions in relation to the number of estimated casualties. It 
further assists the health planner with valuable information on the estimated medical 
resources required to address the expected casualties. This is probably one of the most 
important aspects as it allows the medical commander to determine what resources are 
required to allow for the planning and deployment of the correct systems at the correct 
place, especially when using a “Building Block” health support system as is utilised within 
the SAMHS. This will ensure optimal utilisation of scarce resources. 

Some of the data provided gives an indication of the anticipated number of casualties, 
the type and classification of injuries, hospital beds required, evacuation requirements in 
terms of numbers and expected flow, and, of course, the need for medical logistics 
including pharmaceuticals, blood and blood products, and more. It further serves as an 
indicator of resources required from other services, like aircraft for medical evacuation 
and special logistical requirements. This contributes to a more comprehensive 
sustainment requirement in the joint environment for the operational commander and 
staff to consider when planning a particular mission. 

Casualty estimation is not an exact science but it attempts to include a vast number of 
factors to be analysed and considered to achieve a very realistic estimate. Although 
casualty estimation tables refer to exactly that, namely casualties, one often only thinks 
of the wounded or dead and tends to forget about the Disease and Non-Battle Injuries 
(DNBIs). Underestimation of aspects like acclimatisation, local health profiles, 
infrastructure and climate may cause an over-burdening of an already taxed HSS 
system. The importance of understanding the fluctuation in sick reporting levels during 
various stages of the campaign may have serious implications for force level 
maintenance. Disparities in figures calculated for various forces are also significant in the 
sense that generalised calculations for casualty estimates cannot be based on force 
levels alone. 



4 


The South African National Defence Force (SANDF), like other defence forces around 
the world, also utilises its own casualty estimation tables to perform the necessary tasks 
to ensure a comprehensive health support system in support of the intent and concept of 
operations of the operational commander. The validity and applicability of the currently 
utilised SANDF casualty estimation tables in the modern war theatres are questionable. 

THE CURRENT SANDF CASUALTY ESTIMATION TABLES 

The casualty estimation tables of the SANDF are vested in the Doctrine and earlier 
documents like the Operational Pamphlet of the South African Military Health Service 
(SAMHS)(3). The document originated as a result of the Border war in South West Africa 
(now Namibia) and Angolain which South Africa was involved .The casualty estimation 
tables utilised in South West Africaat the time of the conflict (1966 to 1989) were based 
on available figures utilised for the North Atlantic Treaty Organisation (NATO) forces. As 
casualty estimation tables are more often than not based on the rate of casualties 
experienced, it became apparent that the NATO tables did not address the type of 
warfare experienced by the South African troops and therefore it had to be adapted for 
the type of warfare experienced in Namibia. 

The current doctrine allows for a more flexible approach in the deployment of medical 
resources to areas where the most casualties are expected, making sure that the right 
type of support is at the right place at the right time. In order to achieve this, one must be 
able to calculate the appropriate variables for the specific force levels and circumstances. 
The basis for calculation is still the NATO tables. 


S/No 

Command Level 

BC Rate 

BS Rate 

Total BC Rate 


a 

b 

c 

d 

01 

Battalion 

20.5% 

4.1% 

24.6% 

02 

Brigade 

6.9% 

1 .4% 

8.3% 

03 

Division 

3.0% 

0.6% 

3.6% 

04 

Corps 

1 .4% 

0.3% 

1 .7% 

05 

Army 

1 .0% 

0.2% 

1 .2% 


Table 1: The Planning Statistical Data (4) 



5 


Total Battle Casualty (TBC) rates include the Killed-in-Action (KIA), Captured and 
Missing-in Action (MIA) and Battle Stress / Battle Shock (BS) cases. 


S/No 

Aspect 

Abbreviation 

Percentage of TBC 


a 

b 

c 

01 

Killed-in-Action 

KIA 

17% 

02 

Captured/Missing-in-Action 

CMIA 

8% 

03 

Wounded-in-Action 

WIA 

58% 

04 

Battle Stress Cases 

BS 

17% 


Table 2: The different categories (4) 


The NATO casualty estimation tables provide a general picture for various force levels 
ranging from battalion to an army size and provides a general idea of casualties expected 
.especially from the perspective of the operational-level commander. No specifics with 
regard to activities, smaller groupings in support of the focus of main effort or tactical 
considerations are included in detail. This may prove sufficient to a degree at the military 
strategic and operational levels of war, but lower down, especially for health care, these 
are inadequate especially looking at DNBIs again. 

UTILISING THE CURRENT TABLES FOR CALCULATION 

A recent attempt at the SA National War College (SANWC) to create an electronic 
instrument (MS Excel-Based) to assist in calculating casualties during campaign planning 
proved more difficult than anticipated. Current tables are oversimplified and cannot 
address the specific needs of health planners or commanders. Not enough specifics and 
variables are available to everyone in the joint environment, with little reference to the air 
component and little to no reference to the maritime component. This will require future 
research to rectify the shortcomings. 

These aspects are further exacerbated when functioning in the joint and multi-national 
environment. The result of utilising generic tables may lead to very high numbers being 
estimated, and therefore the commander tends to underplay the value of this instrument. 


The casualty estimate is the backbone of operational health planning, and should 



6 


therefore be an embedded skill in all military health practitioners, especially planners. 
This no longer seems to be the case. Furthermore, the current tables, although practical, 
may be outdated and require further development and refinement based on real-time 
information and statistical data. 

COMPARISON WITH OTHER COUNTRIES 

The British Military indicates that specific Casualty Estimation would only be done if the 
specific threat is known. They refer in their doctrine to Generic and Operationally Specific 
Estimates (5). Generic Estimates are used in the absence of a specific threat whereby 
the generic rates, such as those published by NATO, are still utilised. Operationally 
Specific Estimates, on the other hand, are used when a particular threat is identified. This 
allows for detailed planning and resource allocation. The main steps in estimating both 
are the same. 

Firstly, it determines the Population at Risk (PAR). 

Secondly, the Casualty Rate is estimated on a pro rata basis across the PAR 
expressed as a rate over time, or as the total numbers of casualties expected for 
particular engagements. 

Thirdly, the Casualty Profile is calculated as a relative proportion of different 
casualty types. 

Lastly, the Casualty Flow refers to when casualties are expected and the gaps 
between these periods. 

In the Allied Joint Medical Support Doctrine as used by the US (6), it is also reconfirmed 
that casualty estimates are the core of medical plans. In any scenario, the analysis of 
likely casualty rates and numbers has a great political and operational significance and is 
fundamental to establishing the medical support requirements. It is a prediction of total 
personnel losses in an operation due to various causes expressed in numbers per day. 
The various casualties are also broken down into Battle Casualties (BC) and Non-Battle 
Casualties (NBC). 



7 


BC includes Killed, Captured and Missing-in-Action (KCMIA), Wounded-in-Action (WIA) 
and cases of Battle Stress (BS). Non-Battle Casualties include Disease and Non-Battle 
Injuries (DNBIs). It further describes the casualty rate as a daily rate (number of 
casualties/1000 men/day). 

Although the SANDF tables are similar to the NATO approach, as well as the nations 
mentioned, the big difference is the fact that more detail is considered if the particular 
threat is known. A lot more emphasis is placed on the importance of DNBIs as well as the 
Theatre of Operation (TOO) where the conflict is taking place. Therefore, note the 
importance of realising and addressing the various health profiles, not only of the country 
in which the conflict is taking place, but also that of the Troop Contributing Nations. 

In comparing the various policy documents utilised by the United Kingdom, NATO, the 
USA, as well as the RSA for determining casualty estimates, one cannot help but realise 
that the fundamental elements are similar in terms of the variables considered in the 
calculation. Although the fundamental ideas are similar, there are still some differences- 
the biggest of which is the extent to which the various factors can be adapted and 
interpreted. The Army Casualty Estimator (used by the USA) allows for many more 
options within a specific element than any of the other doctrines. 

However, what is very important in these comparisons, is that the elements that are 
utilised are all applicable to the commander’s battle design and, therefore, it again 
stresses the importance of joint planning with the medical staff being up to date with the 
requirements and vision of the commander to determine realistic casualty estimates. 

A second very important aspect of the U.S. doctrine includes matters such as Fauna and 
Flora, disease, displaced persons and local resources, which again underlines the 
importance of Health Intelligence in determining the art of the possible. 

The third aspect is the ease of working with the computerised casualty estimation tool 
which provides realistic casualty estimation based on the applicable data. This makes the 
calculation easier and quicker, but also more trustworthy than a generic percentage 
coupled to specific force levels. The biggest drawback of the particular tool is the fact that 



8 


it is basically limited to the tactical level and does not allow for a quick calculation of 
overall casualty figures on the operational level. 

CHANGING NATURE OF WARFARE 

The Gulf War of 1991 stands out from other conflicts experienced in the 20 th Century iro 
the low number of casualties experienced by the Coalition and Iraqi forces. In total, more 
than a million military personnel from both sideswere involved. On the Coalition side, the 
United States lost 147 Killed-in-Action (KIA), Britain lost 24 and Saudi Arabia 29(7). 

It is relatively easy to determine the casualties post conflict as it is a mere case of 
calculation. With different systems being utilised by various countries, calculating the 
injured proofs to be more complex. General consensus is however that around 450 
soldiers of the United States were injured, with a similar number from the rest of the 
coalition. 

It is important to note that other causes of death and serious injury amounted to 1500 for 
the United States. British Forces that lost only 24 members KIA had to return 700 of their 
personnel home due to illness or accidents. The current tables focus on Battle Casualties 
but underplay DNBIs. The Operational Commander must utilise such calculations to 
ensure mission success. In the case of the Gulf War, penetrating deep into Iraq and 
planning to stay a long time, casualty estimates were at the heart of the planning. The 
commander would select a combat plan shaped by these assessments, but still the 
actual number of casualties could not be predicted. 

The military today is being tasked with broader security missions. It is expected to tackle 
challenges ranging from peacekeeping to the proliferation of weapons of mass 
destruction. Providing humanitarian aid, combating terrorism, and confronting 
international drug cartels and organized crime are among the support duties. This means 
that troop requirements will not change significantly. The Armed Forces will continue to 
need substantial numbers and tactical leaders with the motivation, skills, and mental 
agility to operate decisively in a complex, confusing, and dangerous international arena. 

As one can imagine, these operations bring their own dimensions and challenges and 
this is equally true in terms of the estimation and prediction of casualties. Although these 



9 


operations may in some sense be referred to as Military Operations Other Than War 
(MOOTW), they are not the focus of the current casualty estimation tables. 

War in its full essence is not a thing of the past, but there seems to be a shift in the 
conventional role of the Military of tomorrow towards MOOTW. On the strategic and 
political level it would mean lower body counts in exercising foreign policy and would be 
more acceptable to the public at large. The operational level commander and staff will be 
confronted with fewer resources and financial backing than during war but may be 
required to perform an array of tasks within the scope of this limited resource pool. For 
the health planner, it would mean fewer battle casualties and more DNBIs- a significant 
mind shift. The changing environment of the complex emergencies in which the militaries 
of the world find themselves demands that proper planning for all contingencies must be 
done effectively to ensure that the military can function in an efficient and cost-effective 
way. 

CONCLUSION 

Casualty estimates are and will remain major resource drivers and, although an inexact 
science, accuracy is important. The existing casualty estimation tables in use in the 
SANDF may not address the level of accuracy that is required, especially in the current 
battle space. The environment in which the militaries of the world find themselves is 
changing so rapidly iro the role and complexity of modern conflicts that the Military must 
adapt constantly so as not to be caught unawares. The SANDF, and the SAMFISin 
particular, cannot be reactive in trying to address the important aspects of 
comprehensive health care on the battlefield. Central to this is proper planning of 
resources required to maintain force levels. With proper planning, poor performance is 
prevented. Casualty Estimation Tables are at the core of health planning and determine 
the ultimate risk to human life, the implications of which can and will be felt on tactical, 
operational as well as strategic levels. It is therefore important that they must be 
contemporary, realistic and practical to ensure that the commander has the correct risk 
indication and that the soldier receives the health care which he or she deserves on the 
battlefield. 



10 


REFERENCES 

(1) Senate Armed Services Committee, USA. Hearing on the Nomination of William Cohen as Secretary of 

Defence. [Online].; 1997 [cited 2010 January 19. Available from: 
"www.pcinegi.udlap.mx/infoUSA/politics/biograph/2142.htm” 

(2) United States of America Department of Defence. Planning for Health Service Support: Field Manual 

(FM8-55:1013) Washington: Department of Defence HQ; 1994. 

(3) South African Military Health Service. Operational Pamphlet MS3/13/90(E). 1990. 

(4) Allied Command Europe. Medical Support Principles, Policies and Planning Parameters. Directive 85- 
8 . 

(5) United Kingdom Army. Doctrine Publication Volume 3: 2E-1 : Logistics: Medical Supplement: Army 

Code 71670. 

(6) NATO Standardisation Agency. Allied Joint Medical Support Doctrine (AJP4.10) Brussels: NATO Office 

of Information and Press; 2002. 

(7) Finlan A. Essential Histories: The Gulf War United Kingdom: Osprey Direct; 1991. 



Triage in the Combat Scenario as a Tool for the Optimal 
Treatment and Evacuation of the Wounded Soldier 


Maj (Res) R.C. Grobler 

Dip Nurs, Dip Clin Nurs Sc 

Service Line Director, Bokamoso Hospital, Gaborone, Botswana 


Maj P.J. van Aswegen 

M Soc Sc (Critical Care) (UOFS), B Soc Sc (Nursing) (UOFS), BA Cur (/ et A) (UNISA), OECP, AEA 
School for Military Health Training 


ABSTRACT 


Deciding which patient to treat first when more than one patient requires medical 
treatment is a decision that must be made on scientific grounds. The use of 
evidence-based triage protocols could significantly help medical personnel in 
making the decision. 

Patients are prioritised into categories according to the life or limb threatening level 
of their injuries. The higher the category, the more severe the injuries and the more 
urgent the medical treatment required. 

Triage SIEVE is a model based on the mobility and ABC (Airway, Breathing and 
Circulation) presentation of the patient. This model is used to perform initial / 
primary triage and is presented in an easy-to-follow algorithm. 

Triage SORT takes into consideration anatomical and physiological parameters of 
the patient. Clinical knowledge and experience are important in the interpretation of 
the patient’s presenting signs and symptoms in order to make a decision. 

On the battlefield, reversed triage may be used. In this scenario, the patients with 
minor injuries are treated before patients with more serious injuries in order to return 
them to the battlefield. 



INTRODUCTION 


Triage was initially developed by Dominique Jean Larrey (1,5), a surgeon during the 
Napoleonic Wars (1803-1815). He realised that casualties must be sorted into priorities of 
care to optimise care without taking their military rank into consideration. His objective was 
however to treat the less injured first to get them back to battle as soon as possible. 

Triage existed in the past but only informally. It was only during World War I (5) (1914 — 
1 91 8)that formalised triage was initiated by French doctors who were treating the wounded 
on the battlefield as well as at the aid stations behind the front. 

Until recently, triage was frequently performed as a matter of “the best guess” based on the 
experience and perception of the triage officer as opposed to a meaningful assessment 
based on repeatable criteria. 

In the past, victims of war or casualties were prioritised according to three basic categories: 

• Those who are likely to live, irrespective of what care they are going to receive 

• Those that are likely to die, irrespective of what care they are going to receive 

• Those for which immediate care might have a positive outcome 

The modern-day approach in triage of casualties has become more scientific, based on 
scientific criteria and repeatable by different triage officers. Patients are now classified 
according to the following categories (4,5): 

PI: Critical: Those in need of immediate life-saving treatment. 

P2: Urgent: Those in need of medical treatment that can be delayed for a limited time 
period. 

P3: Minor: Those in need of minor medical treatment. 

P4 (PI Hold): Patients not salvageable with the resources available or who are so severely 
injured that they cannot be saved. 



Dead: A patient that is dead As there is no priority coupled to the management of the 
dead, corpses are not allocated a priority. 

During the primary or initial triage, the clinical interpretation and the knowledge of the 
specific signs and symptoms of the wounded soldier’s injuries are not needed (5). Initial or 
primary triage is thus based on an easy-to-follow algorithm. Due to the simple nature of the 
algorithm, non-clinical staff (eg pharmacists, social workers, and psychologists) can be 
used at this level as triage officers. This will leave trained and skilled medical staff 
(Operational Emergency Care Practitioners, Nursing Officers and Medical Officers) free to 
initiate treatment of the wounded soldier. 

Secondary triage is more scientific and clinical knowledge-based (5). Specific signs and 
symptoms are taken into account in the assignment of a specific triage priority. Personnel 
that perform secondary triage thus require clinical training and experience. 

The aim of triage is to ensure the greatest good (care) for the greatest number of casualties 
to ensure the optimal utilisation of medical personnel, equipment, and facilities (4,5). 

TRIAGE PRIORITIES 

Within the South African Military Health Service, as in the Emergency Medical Services 
three standard triage priorities are distinguished with a possible forth grouping used in 
exceptional circumstances. 

Priority 1 - Critical 

Patients classified as Priority 1 (PI) require immediate interventions or even surgery in 
order for their life or limb to be saved. To put it more simply, if the patient does not receive 
immediate medical attention, the patient will die. The key to successful triage is to identify 
these individuals as quickly as possible. Examples of patients in this category include, but 
are not limited to, haemodinamically unstable patients with airway obstruction, chest or 
abdominal injuries, massive external bleeding, or shock (4). As a planning norm, this 
grouping on average represents 10% of the live casualties in battle or in a major incident. If 
a colour coding system is used, this category is marked RED. 


Priority 2 - Serious 

Patients classified as Priority 2 (P2) are injured in such a way that they might require 
surgery or constant medical attention. The patient’s general condition, however, permits 
that if surgery is needed; it may be delayed for a couple of hours. Examples of injuries that 
would be as signed to a P2 category include, but are not limited to, large tissue wounds, 
fractures to the major bones, intra-abdominal or thoracic wounds or burns to less than 20% 
of the body surface area. Medical treatment such as splinting and pain control will be 
required (4). On average this priority represents 15% of the surviving casualties. In a colour 
coding system, this category is marked YELLOW or ORANGE. 

Priority 3 - Non-Urgent or Minor 

Patients classified as Priority 3 (P3) have minor injuries, the so-called walking-wounded. 
They do not require immediate life saving medical interventions. When colours are used to 
indicate the classification, P3 is indicated by GREEN. Examples of patients in this category 
include, but are not limited to, small burns, lacerations, abrasions and small 
fractures(4).This priority is on average the largest group of casualties and represents 75% 
of the surviving casualties 1 . 

Priority 4 (or PI HOLD) 

Patients classified as Priority 4 (P4)are so severely injured or moribund that their chance of 
survival is almost non-existent, given the resources available for their treatment (4,5). In 
some triage systems, the terms PI Hold or expectant are used to identify this category of 
patients. 

The P4 priority is the casualty who would have been a PI priority, if there were adequate 
resources available. However, with the P4 priority, the treatment of the patient cannot be 
initiated with the resources available at that moment in time. 

The P4 priority is activated to do “the greatest good for the greatest number of patients” 
taking into account the limited resources available. If more resources become available, 
any surviving P4 patients are immediately re-triaged to PI for immediate care (6). 


1 It is emphasised that the distribution of 10% Priority 1, 15% Priority 2 and Priority 3 75% are planning norms based on 
analysis of battlefield statistics. 



Patients in this priority must still be provided with comforting measures and pain medication 
and must be treated with the necessary respect (4). 

TRIAGE SIEVE 

The Triage Sieve method (Diagram 1) can also be referred to as primary or initial triage (5). 
Triage Sieve is used as an initial tool for the fast and simple prioritising of a large number of 
casualties simultaneously. 

Triage Sieve is a quick “first look” triage to prioritise the many casualties for care. Clinical 
interpretation on how the patient’s condition may change must not be taken into 
consideration. As the Sieve method is a simple procedural method of triage, the use of non- 
clinical personnel to perform Triage Sieve may be considered during this phase to optimally 
use clinical personnel to provide emergency interventions and execute more advance triage 
procedures. 

Triage Sieve is based on two fundamental principles: Mobility and the ABC (Airway, 
Breathing and Circulation). 

Mobility. 

The first step is determining the mobility of the patient. Patients that can still walk are 
prioritised as P3. It does not matter if the patient has a laceration, fracture, or any other 
injury. As long as the casualty is able to move/walk on his/her own he/she is prioritised as a 
P3 patient. The patient is immediately directed to the P3 treatment area. 

Should the patient be seriously injured, but able to walk he/she is still triaged as P3 at this 
stage and is directed to the P3 treatment area where skilled medical staff evaluates every 
patient using secondary triage methods. 



Airway and Breathing: 

The second step is to determine whether the casualty is breathing. If the casualty is not 
breathing, the airway is opened with simple airway manoeuvres such as chin-lift or jaw- 
thrust and breathing effort re-assessed. If breathing is absent, the patient is considered to 
be dead 2 . 

If breathing is detected once the airway is opened, the patient is prioritised as PI - airway 
problem. This patient is immediately transferred to the PI resuscitation area. 

For casualties who were breathing, the respiratory rate is used as a tool to determine 
effectiveness of ventilation. If the respiratory rate is below 9 or above 30, the casualty is 
prioritised as PI- breathing problem. This patient is immediately transferred to the PI 
resuscitation area. 

If the breathing rate is between 10 and 29, continue to the next step on the Triage Sieve 
algorithm assessing circulation. 

Circulation: 

The third step is to do an assessment of the circulatory status of the patient. Circulation is 
assessed by means of the pulse rate (radial). If the pulse rate is above 120, the casualty is 
prioritised as PI - circulatory problem. This patient is immediately transferred to the PI 
resuscitation area. 

Capillary Refill Time (CRT) can also be used as an indicator of the circulatory status, 
however, evaluating capillary refill time might be difficult in the combat scenario due to 
austere conditions. In the dark, sufficient light is needed to accurately assess capillary refill 
time. Switching on a light in the dark, austere battlefield environment will make the medical 
personnel immediate targets. Cold conditions and subsequent hypothermia also make CRT 
an unreliable indicator. Assessing CRT needs to be used with caution. . If the capillary refill 
time is longer than 2 seconds, the casualty is prioritised as PI - circulatory problem. 


2 It must be emphasised that Triage Sieve is used in the Major Incident or disaster situation where a large number of 
patients need to be assessed and prioritised in the shortest possible time. It is within this environment that the patient 
with an open airway that is not breathing is classified as dead. If more resources are available, the more advance Triage 
Sorting tool may be utilised. 



P2 ALLOCATION 

If all of the abovementioned criteria are within the normal limits of the algorithm, the 
casualty must be prioritised as a P2 priority and transferred to the P2 treatment area. P2 
patients therefore have a pulse rate of less than 120 beats per minute or a capillary refill 
time of less than 2 seconds. 

TRIAGE SORT 

Triage Sort (Diagram 2) is performed as the secondary triage (5). Triage SORT is thus 
performed when more resources, time and skilled personnel are available, such as at the 
stabilisation point, the Level 1 Resuscitation Post and at the Level 2 Field Hospital. Often, 
when a large group of patients arrive simultaneously, they are first triaged using the sieve 
method to get them into specific categories, then every category is revisited and the 
casualties re-evaluated using the more refined Triage Sort method. 

Diagnostic equipment (blood pressure monitors) must be available to aid in assigning triage 
priorities. 

Triage Sort is a physiological measure of the severity of the casualty’s injuries based on the 
following three parameters: Glasgow Coma Score, Respiratory rate and Systolic Blood 
Pressure. 

Step 1: Determine the Glasgow Coma Score of the casualty. 

Step 2: Determine the Systolic Blood pressure of the casualty. 

Step 3: Determine the Respiratory rate of the casualty and convert the respiratory rate to a 
value using the scale provided. 


Step 4: Assign a score according to the measured value for each physiological variable. 



s 

No 

Physiological 

Variables 

Measured Value 

Score 


A 

b 

C 

1 

Glasgow 

3 

0 


Coma Score 

4-5 

1 



6-8 

2 



9-12 

3 



13-15 

4 

2 

Systolic Blood 

0 

0 


Pressure 

<49 

1 



50-75 

2 



76-89 

3 



>90 

4 

3 

Respiratory 

0 

0 


Rate 

1-5 

1 



6-9 

2 



>30 

3 



10-30 

4 


Table 1 : Measured Values and Scores of Physiological Variables 


Step 5: Add up the allocated scores: Glasgow Coma Scale + Systolic Blood pressure + 
Respiratory Rate. (Note the original Glasgow Coma Score total is not added in but only the 
converted score is used) 




Step 6: Determine the triage priority according to the accumulative score. 


SNo 

Score 

Triage Priority 


A 

B 

1 

1-10 

Priority 1 

2 

11 

Priority 2 

3 

12 

Priority 3 

4 

1-3 

Priority PI Hold/ P4 

5 

0 

Dead 


Table 2: Triage Sort - Score and Triage Priority 


Step 7: Take into account anatomical and physiological aspects that may have an effect on 
the nature of the injury. The Triage Officer may use clinical judgement and assign a higher 
triage priority to the patient based on specific findings indicating the need for more urgent 
treatment of the patient. It must be emphasised that the use of clinical judgement to 
upgrade a patient’s triage priority must be based on observed findings and not on possible 
deterioration of the patient’s condition. For example, a walking casualty with facial burns 
may be heamodynamically stable and based on clinical findings be categorised as a Priority 
3 casualty, however, due to clear facial burns, singed facial hair and soot on the tongue, the 
patient requires intervention to maintain an airway and is therefore upgraded to a Priority 1 - 
airway patient. 

This action must, however, be used with great caution to prevent large numbers of 
casualties being upgraded to Priority 1 based on assumed possible complications and 
cluttering the emergency treatment capability. 

TRIAGE IN THE OPERATIONAL SCENARIO 

The choice of which triage system to use in the operational scenario will depend on the 
location and resources available (1). 

On the battlefield, triage takes place within an area with already limited resources. Triage 
determines if casualties should receive immediate treatment, eg application of a tourniquet 




to stop catastrophic bleeding, or whether transfer to the stabilisation point is possible. In this 
situation, Triage Sieve will be applied continuously and repeated at each point in the 
evacuation chain until the casualty reaches an area where a more refined triage method 
can be used. This is often only possible when the casualty reaches the Level 1 
Resuscitation Post. 

Basic principles that can aid in the triage process on the tactical battlefield environment are 
(4): 

1 . Movement of the casualty and attendant out of danger take precedence over a life saving 
procedure or other medical interventions. Casualties who are not clearly dead may be 
moved to cover, if possible, and / or on command of protection forces. 

2. Perform an initial rapid assessment of the casualty as soon as cover is reached. This 
assessment should not take longer than 60 seconds (1 minute) per casualty and includes 
Triage Sieve. 

3. Treat any life-threatening haemorrhages and perform life-saving interventions as 
needed. For example, to open airways, stop bleeding and stabilize injured limbs will save 
lives and reduce further injuries. Pressure dressings and tourniquets are very useful tools to 
prevent catastrophic bleeding, which is a major cause of deaths on the battlefield. 

Please take note that these principles apply to the combat scenario where there are limited 
resources. Care under fire poses a lot of challenges to the medical personnel, especially 
with haemorrhage control that takes priority. 

Initiating the Priority 4 (PI HOLD or expectant) category can be forced by the tactical 
situation. It is thus advisable to obtain sanction from the higher headquarters (HQ) to 
initiate the Priority 4 category at the Level 1 Resuscitation facility. The higher HQ is more 
aware of the complete tactical situation at hand and the possibility of receiving more 
resources. If more resources become available or, due to the tactical situation, no more 
patients will be arriving at the specific facility, all currently available resources can be used 
for the treatment of the patient. If, however, the higher head quarters are aware of a hostile 
action taking place with resulting large numbers of casualties, it may advise that the Priority 



4 category is used to free-up resources for additional casualties that are on the way. It must 
be emphasised that the decision to activate the Priority 4 category is seldom taken and 
must be based on a proper tactical appreciation of demand versus resources. 


The United States of America Marine Corps describe the principles of tactical / battlefield 
triage as follows (5): 

1 ) To accomplish the greatest good for the greatest number of casualties. 

2) To employ the most efficient use of available resources. 

3) To return personnel to duty as soon as possible (Reverse Triage). 


REVERSE TRIAGE 

In some situations the preservation of fighting power may be of utmost importance for the 
survival of the element. In these instances it might be necessary to treat less seriously 
wounded or injured before the severely wounded or injured casualties to get them back 
fighting. As the less injured are treated to the level that they can return to the fighting, 
efforts can then be redirected to the seriously wounded that will require all available 
resources to be treated. This concept is called reverse triage where Priority 3 casualties are 
treated/stabilise first to get them back fighting, then try to save the priority 1 and 2 
casualties. 

in certain scenarios, it might be of the utmost importance to direct the medical resources 
first towards the injured medical personnel as this may be advantageous to ensure that they 
survive to continue with the treatment of the injured soldiers / casualties. 

Triage is not a democratic decision-making process and requires very tough decisions in a 
very short time. The “return to battle” or a “fight to save the ship” is a tactical scenario that 
may take precedence over “best medical care practice” (1,2). The decision to initiate 
reverse triage can thus be forced by the tactical situation and not only by the clinical 
decision making process. 



RE-TRIAGE 


Triage is never a one-off process. It is repeated continuously at every link of the evacuation 
process and after each intervention. At arrival on the scene of a Ratel vehicle that was shot 
out by enemy fire, that has been declared safe by the fighting element, the medic will 
assess all casualties using Triage Sieve and allocate priorities. The team will then use 
these priorities to extricate the casualties from the vehicle to a stabilisation point. At the 
stabilisation point all casualties are re-triaged using Triage Sieve to determine their present 
condition to determine the need for intervention. After interventions, for example, inserting a 
naso-pharyngeal airway and applying a bomb bandage, the casualty is re-triaged as his/her 
condition may now be more stable. This process is repeated continuously. 

EVACUATION 

Two key factors must be considered in making a decision on the evacuation of a casualty to 
a higher level of care, namely the current triage priority and the required treatment^). 
These two factors are used to triage the casualties for evacuation. 

Triage Priority 

As indicated above, the patient must be re-triaged after receiving any form of treatment. 
Additional criteria must then be added to determine the evacuation priority. The triage 
priority alone may not be the sole determination for evacuation priority. The availability, type 
and capacity of vehicles are examples of additional criteria that must be kept in mind and 
added during the decision making process regarding the patient’s evacuation priority. If, for 
example, after initial treatment the patient is re-triaged and his/her priority has changed 
from P2 to P3, a sophisticated means of transport is not needed and his/her need for 
immediate transport to a higher facility is less urgent. The first available mode of transport 
may not be the appropriate mode for the specific casualty and the team may decide to 
evacuate the priority 2 casualties with the available ambulance and hold the priority 1 
casualty back for the helicopter confirmed to be landing within a few minutes’ time. The 
most appropriate means of evacuation must be used to ensure that each patient reaches 
the next level of care alive. 



Treatment 

The correct amount of treatment is necessary to ensure that the patient survives to the next 
level of care. According to the patient’s priority classification, treatment and packaging must 
be restricted to what is necessary for safe and effective evacuation. An unstable casualty 
results in an unstable evacuation. It may be indicated to hold back a higher priority to 
complete preliminary stabilisation while a lower priority casualty is evacuated first. 

Often the team is confronted with two or more casualties with the same triage priority, but 
only space to evacuate one casualty. In this type of situation, the criteria of who will benefit 
the most by the treatment at the next level of care must be considered as additional criteria 
to determine evacuation priority. 

Evacuation triage, therefore, not only uses Triage Sieve or Sort, but also considers the 
additional criteria of treatment requirement to determine the evacuation priority. 

CONCLUSION 

Casualties must be triaged at every link of the evacuation process (chain) as triage is a 
dynamic process and the casualty’s condition can deteriorate at any time, or improve after 
received treatment. 

Triage in the tactical situation is an art that requires situational awareness, decisiveness 
and clinical expertise. Each decision is driven by factors such as the personnel versus the 
casualty ratios, provider skills, accessibility of equipment, and the availability of evacuation, 
communication and supplies. Time, distance and weather may also play significant roles as 
do fatigue, confusion and panic(l). Triage Sieve provides the tool for scientific triage at this 
level. This can be done by any person available on scene. 

As soon as a casualty reaches more appropriate levels of care where more resources are 
available, a more detailed triage process can be used. Triage Sort provides the tool for this 
assessment, but requires clinical knowledge, equipment, time and capability to calculate 
scores. It is recommended that it is used from the Level 1 Resuscitation Post to the Level 3 
Specialist Hospital. 



The category of Priority 4 is a very specific category reserved for very specific situations 
where the need totally overwhelms the available resources and it is very seldom activated. 

Reverse Triage refers to a unique system to optimise treatment to preserve fighting power 
in a desperate battlefield situation. 

Evacuation Triage uses the same system but additional criteria are taken into account. 

REFERENCES 

(1) Baker M.S. Creating Order from Chaos: Part 1: Initial Care and Tactical Considerations in Mass Casuaty and Disaster 

Response. Military Medicine. 2007 March; 172(3): p. 232-236. 

(2) Baker M.S. Creating Order from Chaos: Part II: Tactical Planning for Mass Casualty and Disaster Response at 

Definitive Care Facilities. Military Medicine. 2007 March; 172(3): p. 237-243. 

(3) Janousek J.T., Jackson D.E., DeLorenzo R.A., Coppola M. Mass casualty triage knowledge of military medical 

personnel. Military Medicine. 1999 May; 164(5). 

(4) United States Marine Corps. FMST Student Manual. [Online].; 2008 [cited 2009. Available from: HYPERLINK 

"http://www.operationalmedicine.org/TextbookFiles/FMST_2008/FMST_1421.htm" 

(5) Advance Life Support Group. Major Incident Medical Management and Support: A practical approach at the 
scene London: BMJ; 2007. 

(6) Ligthelm T.J., Du Plessis H.J.C. Operational Trauma Treatment Algorithm. MILMED Scientific. 2008 February; 1(1): p. 


39-43. 



Triage SIEVE 



BREATHING 


NO 


OPEN 

AIRWAY 


BREATHING 



YES 



URGENT 
PRIORITY 2 


Diagram 1 : Triage SIEVE 








Triage SORT 

Step 1 : Determine the Glasgow Coma Score (GCS) of the casualty 


A: Eye Opening 

B: Verbal Response 

C: Motor Response 

Spontaneous 

4 

Orientated 

5 

Obeys commands 

6 

To voice 

3 

Confused 

4 

Localises 

5 

To pain 

2 

Inappropriate 

3 

Pain withdraws 

4 

None 

1 

Incomprehensible 

2 

Pain flexes 

3 



No response 

1 

Pain extends 

2 





No response 

1 


Step 2: Determine Systolic BP 


Step 3: Determine Respiratory Rate 


Step 4: Assign a score according to the measured value of each variable 


Systolic BP 

Score 

Respiratory Rate 

Score 

GCS 

Score 

>90 

4 

10-30 

4 

13-15 

4 

76-89 

3 

>30 

3 

9-12 

3 

50-75 

2 

6-9 

2 

6-8 

2 

1 -49 

1 

1 -5 

1 

4-5 

1 

0 

0 

0 

0 

3 

0 


Step 5: Add up the allocated scores 

3 + Respiratory Rate + Glasgow Coma Score 

= Accumulative Score 


Step 6: Determine the Triage Priority according to the accumulative score 


Accumulative Score 

Triage Priority 

1 - 10 

Priority 1 

11 

Priority 2 

12 

Priority 3 

1 -3 

PriorityP4 (PI Hold) 

0 

Dead 


Step 7: Take into account any anatomical or physiological aspects that may have an effect 
on the nature of the injury. Triage Officer may assign a higher triage priority. 


Diagram 2: Triage Sort 



Airway Management in the Military Environment 


LtCol (Res) A. Groenewald 

MB ChB (UF), M Fam Med (UF), MFGP(SA), Dip PEC (SA), MSc (Sport Med) (UP) 

General Practitioner, Private Emergency Unit, Pretoria 

Part-time lecturer, Emergency Division, University of the Witwatersrand 


ABSTRACT 


Obtaining and maintaining the airway in the battlefield casualty can make 
the difference between life and death. The article explains the management 
of the airway in a casualty beginning with basic manoeuvres and 
equipment all the way to the advanced airway with alternative devices, 
supraglottic devices and the surgical airway. The specific management of 
the airway in the challenging conditions of the battlefield is discussed 
under the different phases encountered on the battlefield. 


INTRODUCTION 

Airway management is the “A” in the ABODE algorithm primarily used by all 
emergency medical personnel in any critically ill casualty. Failure to maintain 
oxygenation and ventilation in a casualty will lead to secondary brain injury and 
even death. Adequate airway management and ventilation which provide 
sufficient oxygen delivery to all parts of the body and especially to the brain are 
the most important components of critically ill or injured casualty care. 


BASIC AIRWAY MANAGEMENT 



Recognition of airway compromise and the contributing factors are critical in 
deciding between the various basic options available to open the airway. The 
talk-look-listen-feel approach is taught world wide as part of evaluating a possible 
compromised airway as well as contributing factors. (1) Utilising basic airway 
manoeuvres is crucial in stabilising and opening the casualty’s airway initially. It 
is sometimes the only option available to a health care provider and sometimes it 
is the only manoeuvre necessary in stabilising the airway of the casualty. 

Talk to the casualty. An appropriate reply in a normal voice indicates a patent 
airway, sufficient breathing and adequate brain perfusion for that moment. Any 
inappropriate or incomprehensible response suggests a decreased level of 
consciousness, airway compromise, breathing compromise or all three. (1) 

Look for chest rise, obstruction/foreign bodies in the mouth and pharynx - any 
abnormal behaviour like agitation, confusion, drowsiness and signs of cyanosis 
can indicate oxygenation compromise. (1) 

Listen for any signs of breathing, any abnormal sounds. Partial obstruction of 
the larynx can produce snoring, gurgling (mostly liquid) and gargling sounds. 
Laryngeal injury and or swelling can cause hoarseness or stridor. (1) 

Feel for expired air which will indicate breathing attempts. Feel if the trachea is in 
the midline. Although this is a very late sign and should not be relied upon, it can 
indicate a possible tension pneumothorax (1). 

Any possible compromise should be addressed immediately to improve 
oxygenation and to prevent further deterioration of the casualty. 

Clearing of the airway: 

Visible foreign bodies can be swept out of the mouth with a gloved finger. A 
Magill’s forceps could also be used (if the object could safely be grabbed without 



Triage in the Combat Scenario as a Tool for the Optimal 
Treatment and Evacuation of the Wounded Soldier 


Maj (Res) R.C. Grobler 

Dip Nurs, Dip Clin Nurs Sc 

Service Line Director, Bokamoso Hospital, Gaborone, Botswana 


Maj P.J. van Aswegen 

M Soc Sc (Critical Care) (UOFS), B Soc Sc (Nursing) (UOFS), BA Cur (/ et A) (UNISA), OECP, AEA 
School for Military Health Training 


ABSTRACT 


Deciding which patient to treat first when more than one patient requires medical 
treatment is a decision that must be made on scientific grounds. The use of 
evidence-based triage protocols could significantly help medical personnel in 
making the decision. 

Patients are prioritised into categories according to the life or limb threatening level 
of their injuries. The higher the category, the more severe the injuries and the more 
urgent the medical treatment required. 

Triage SIEVE is a model based on the mobility and ABC (Airway, Breathing and 
Circulation) presentation of the patient. This model is used to perform initial / 
primary triage and is presented in an easy-to-follow algorithm. 

Triage SORT takes into consideration anatomical and physiological parameters of 
the patient. Clinical knowledge and experience are important in the interpretation of 
the patient’s presenting signs and symptoms in order to make a decision. 

On the battlefield, reversed triage may be used. In this scenario, the patients with 
minor injuries are treated before patients with more serious injuries in order to return 
them to the battlefield. 



INTRODUCTION 


Triage was initially developed by Dominique Jean Larrey (1,5), a surgeon during the 
Napoleonic Wars (1803-1815). He realised that casualties must be sorted into priorities of 
care to optimise care without taking their military rank into consideration. His objective was 
however to treat the less injured first to get them back to battle as soon as possible. 

Triage existed in the past but only informally. It was only during World War I (5) (1914 — 
1 91 8)that formalised triage was initiated by French doctors who were treating the wounded 
on the battlefield as well as at the aid stations behind the front. 

Until recently, triage was frequently performed as a matter of “the best guess” based on the 
experience and perception of the triage officer as opposed to a meaningful assessment 
based on repeatable criteria. 

In the past, victims of war or casualties were prioritised according to three basic categories: 

• Those who are likely to live, irrespective of what care they are going to receive 

• Those that are likely to die, irrespective of what care they are going to receive 

• Those for which immediate care might have a positive outcome 

The modern-day approach in triage of casualties has become more scientific, based on 
scientific criteria and repeatable by different triage officers. Patients are now classified 
according to the following categories (4,5): 

PI: Critical: Those in need of immediate life-saving treatment. 

P2: Urgent: Those in need of medical treatment that can be delayed for a limited time 
period. 

P3: Minor: Those in need of minor medical treatment. 

P4 (PI Hold): Patients not salvageable with the resources available or who are so severely 
injured that they cannot be saved. 



Dead: A patient that is dead As there is no priority coupled to the management of the 
dead, corpses are not allocated a priority. 

During the primary or initial triage, the clinical interpretation and the knowledge of the 
specific signs and symptoms of the wounded soldier’s injuries are not needed (5). Initial or 
primary triage is thus based on an easy-to-follow algorithm. Due to the simple nature of the 
algorithm, non-clinical staff (eg pharmacists, social workers, and psychologists) can be 
used at this level as triage officers. This will leave trained and skilled medical staff 
(Operational Emergency Care Practitioners, Nursing Officers and Medical Officers) free to 
initiate treatment of the wounded soldier. 

Secondary triage is more scientific and clinical knowledge-based (5). Specific signs and 
symptoms are taken into account in the assignment of a specific triage priority. Personnel 
that perform secondary triage thus require clinical training and experience. 

The aim of triage is to ensure the greatest good (care) for the greatest number of casualties 
to ensure the optimal utilisation of medical personnel, equipment, and facilities (4,5). 

TRIAGE PRIORITIES 

Within the South African Military Health Service, as in the Emergency Medical Services 
three standard triage priorities are distinguished with a possible forth grouping used in 
exceptional circumstances. 

Priority 1 - Critical 

Patients classified as Priority 1 (PI) require immediate interventions or even surgery in 
order for their life or limb to be saved. To put it more simply, if the patient does not receive 
immediate medical attention, the patient will die. The key to successful triage is to identify 
these individuals as quickly as possible. Examples of patients in this category include, but 
are not limited to, haemodinamically unstable patients with airway obstruction, chest or 
abdominal injuries, massive external bleeding, or shock (4). As a planning norm, this 
grouping on average represents 10% of the live casualties in battle or in a major incident. If 
a colour coding system is used, this category is marked RED. 


Priority 2 - Serious 

Patients classified as Priority 2 (P2) are injured in such a way that they might require 
surgery or constant medical attention. The patient’s general condition, however, permits 
that if surgery is needed; it may be delayed for a couple of hours. Examples of injuries that 
would be as signed to a P2 category include, but are not limited to, large tissue wounds, 
fractures to the major bones, intra-abdominal or thoracic wounds or burns to less than 20% 
of the body surface area. Medical treatment such as splinting and pain control will be 
required (4). On average this priority represents 15% of the surviving casualties. In a colour 
coding system, this category is marked YELLOW or ORANGE. 

Priority 3 - Non-Urgent or Minor 

Patients classified as Priority 3 (P3) have minor injuries, the so-called walking-wounded. 
They do not require immediate life saving medical interventions. When colours are used to 
indicate the classification, P3 is indicated by GREEN. Examples of patients in this category 
include, but are not limited to, small burns, lacerations, abrasions and small 
fractures(4).This priority is on average the largest group of casualties and represents 75% 
of the surviving casualties 1 . 

Priority 4 (or PI HOLD) 

Patients classified as Priority 4 (P4)are so severely injured or moribund that their chance of 
survival is almost non-existent, given the resources available for their treatment (4,5). In 
some triage systems, the terms PI Hold or expectant are used to identify this category of 
patients. 

The P4 priority is the casualty who would have been a PI priority, if there were adequate 
resources available. However, with the P4 priority, the treatment of the patient cannot be 
initiated with the resources available at that moment in time. 

The P4 priority is activated to do “the greatest good for the greatest number of patients” 
taking into account the limited resources available. If more resources become available, 
any surviving P4 patients are immediately re-triaged to PI for immediate care (6). 


1 It is emphasised that the distribution of 10% Priority 1, 15% Priority 2 and Priority 3 75% are planning norms based on 
analysis of battlefield statistics. 



Health Care Management of Radiation 
Casualties 


Col B.P. Steyn 

MBChB (UP), M Med (Anaes)(UP) 

Chemical and Biological Defence Advisor to the Surgeon General 


ABSTRACT 


All humans are exposed to certain levels of naturally occurring radiation 
without any harm. Ionizing radiation is radiation that causes ionisation 
of atoms and is potentially harmful to humans. 

The effects of ionising radiation on humans are the result of changes to 
the DNA and other sub-cellular structures with resultant cellular damage 
that may be repairable or may result in cellular death. Radiation effects 
are determined by dose rates, time of exposure and distance from the 
source of radiation. 

High dose rates may lead to Acute Radiation syndrome, which consists 
of four elements, namely haematopoietic syndrome with depression of 
blood forming organs, gastrointestinal syndrome affecting the 
gastrointestinal system, neurovascular syndrome affecting the brain 
and muscles, and cutaneous syndrome affecting the skin. 

Treatment of radiation patients is primarily supportive by some 
additional specialised procedures such as stem cell transplantation 
when required. 

The health care management of patients exposed to radiation is 
complex and demands a well coordinated multidisciplinary effort. 
Therefore, it is necessary that health care personnel have some 
knowledge of the effects and management of radiation injury. 

The fact that the effects of radiation occur after a time period indicates 
that the primary responsibility of emergency workers at the incident is 
to determine the presence and levels of radiation through well 



2 


documented information and monitoring, while treatment will primarily 
occur at hospital level. 


INTRODUCTION 

All living creatures are exposed to certain levels of radiation (background 
radiation) that occurs naturally due to trace amounts of radioactive materials 
that occur everywhere; in the soil, building materials, food and drink, the air, 
our own bodies (muscles, bones, and tissue) and sea water. The earth is also 
subject to radiation from outer space called cosmic radiation. Background 
radiation must always be taken into account when radioactivity is measured. 

Humanly produced radiation, such as X-rays, radiation for diagnostic 
procedures and cancer therapy, and small quantities of radioactive materials 
released into the environment from coal and nuclear power plants are also 
sources of radiation. 

TERMINOLOGY 

In order to have a clear understanding of all the aspects related to radiation, it 
is necessary that some concepts are described. 

Atomic Structure 

The atom is the basic unit of all matter. It consists of a nucleus around which 
one or more electrons circle. The nucleus consists of protons and neutrons. 
Electrons are negatively charged, protons are positive and neutrons have no 
charge. In most atoms there are an equal number of electrons and protons 
and, therefore they have no electrical charge (1 ,2). 

Atoms combine to form molecules which are the building blocks of matter. 



3 


Ionisation 

An ion is an atom that has an electrical charge due to an imbalance between 
the numbers of protons and electrons. 

Ionisation is the process in which an atom or molecule is converted to an ion 
by adding or removing electrically charged particles (electrons or protons) 
from the atom or molecule (1 , 2). 

Radioactivity 

Some natural elements are unstable; their nuclei tend to disintegrate with 
resultant release of energy in the form of radiation. This phenomenon is called 
radioactivity. Radioactive atoms are called radionuclides (1, 2). 

Ionizing Radiation 

The radioactive emissions listed above will increase the ability of any medium 
through which they pass to conduct an electrical current, in other words, they 
will ionise that medium. Therefore, the radiation caused by these emissions is 
called ionizing radiation (1). 

In living tissue ionizing radiation causes damage to organic molecules and 
therefore, to living cells and tissues. In this regard DNA is of particular 
importance. 

Non-Ionizing Radiation 

Non-ionizing radiation does not have the amount of energy needed to ionize 
an atom with which it interacts. 

Sources of non-ionizing radiation include sunlight, microwaves and infrared 
lights. 


Radiation types 

There are four known types of ionizing radiation: 


a. Alpha Radiation . Alpha radiation is produced by alpha particles. 
Alpha particles are heavy, positively charged particles emitted by 



4 


large atoms of elements such as uranium and radium. They can 
only travel a short distance (2,5 - 4 cm) in the atmosphere and can 
be stopped completely by a sheet of paper or by the epidermis. 
However, if alpha-emitting materials are taken into the body, they 
will cause serious biological damage to living cells (1 , 2). 

b. Beta Radiation . Beta particles cause Beta radiation. Beta 
particlesare high-speed electrons. They can travel up to 3m through 
the air and are more penetrating than alpha particles. They can 
pass through up to around 1 cm of water, but are shielded by plastic 
safety glasses and thin metal sheeting such as aluminium. Beta 
particles pose an external and internal hazard to humans (1 ,2). 

c. Gamma Ravs . Gamma rays are not material particles, but energetic 
photons of invisible light. Depending on their energy, they can pass 
right through the human body, but can be stopped by thick walls of 
concrete or lead. Gamma rays pose external as well as internal 
hazards (1 ,2). 

d. Neutrons . Neutrons are uncharged particles and do not produce 
ionisation directly, but their interaction with the atoms of matter can 
give rise to alpha, beta, gamma, or X-rays that then produce 
ionisation 2 . Neutrons have a long range, are relatively penetrating in 
tissue, but are shielded by hydrogenous materials such as water 
and paraffin. 

EXPOSURE TO IONISING RADIATION 

The factors influencing the effects of ionizing radiation are the dose of 
radiation the tissue receives, the duration of exposure as well as the distance 
from the source of radiation. 

Exposure can be acute, prolonged or intermittent. It can occur alone or in 
combination with other injury. 



Airway Management in the Military Environment 


LtCol (Res) A. Groenewald 

MB ChB (UF), M Fam Med (UF), MFGP(SA), Dip PEC (SA), MSc (Sport Med) (UP) 

General Practitioner, Private Emergency Unit, Pretoria 

Part-time lecturer, Emergency Division, University of the Witwatersrand 


ABSTRACT 


Obtaining and maintaining the airway in the battlefield casualty can make 
the difference between life and death. The article explains the management 
of the airway in a casualty beginning with basic manoeuvres and 
equipment all the way to the advanced airway with alternative devices, 
supraglottic devices and the surgical airway. The specific management of 
the airway in the challenging conditions of the battlefield is discussed 
under the different phases encountered on the battlefield. 


INTRODUCTION 

Airway management is the “A” in the ABODE algorithm primarily used by all 
emergency medical personnel in any critically ill casualty. Failure to maintain 
oxygenation and ventilation in a casualty will lead to secondary brain injury and 
even death. Adequate airway management and ventilation which provide 
sufficient oxygen delivery to all parts of the body and especially to the brain are 
the most important components of critically ill or injured casualty care. 


BASIC AIRWAY MANAGEMENT 



Recognition of airway compromise and the contributing factors are critical in 
deciding between the various basic options available to open the airway. The 
talk-look-listen-feel approach is taught world wide as part of evaluating a possible 
compromised airway as well as contributing factors. (1) Utilising basic airway 
manoeuvres is crucial in stabilising and opening the casualty’s airway initially. It 
is sometimes the only option available to a health care provider and sometimes it 
is the only manoeuvre necessary in stabilising the airway of the casualty. 

Talk to the casualty. An appropriate reply in a normal voice indicates a patent 
airway, sufficient breathing and adequate brain perfusion for that moment. Any 
inappropriate or incomprehensible response suggests a decreased level of 
consciousness, airway compromise, breathing compromise or all three. (1) 

Look for chest rise, obstruction/foreign bodies in the mouth and pharynx - any 
abnormal behaviour like agitation, confusion, drowsiness and signs of cyanosis 
can indicate oxygenation compromise. (1) 

Listen for any signs of breathing, any abnormal sounds. Partial obstruction of 
the larynx can produce snoring, gurgling (mostly liquid) and gargling sounds. 
Laryngeal injury and or swelling can cause hoarseness or stridor. (1) 

Feel for expired air which will indicate breathing attempts. Feel if the trachea is in 
the midline. Although this is a very late sign and should not be relied upon, it can 
indicate a possible tension pneumothorax (1). 

Any possible compromise should be addressed immediately to improve 
oxygenation and to prevent further deterioration of the casualty. 

Clearing of the airway: 

Visible foreign bodies can be swept out of the mouth with a gloved finger. A 
Magill’s forceps could also be used (if the object could safely be grabbed without 



Triage in the Combat Scenario as a Tool for the Optimal 
Treatment and Evacuation of the Wounded Soldier 


Maj (Res) R.C. Grobler 

Dip Nurs, Dip Clin Nurs Sc 

Service Line Director, Bokamoso Hospital, Gaborone, Botswana 


Maj P.J. van Aswegen 

M Soc Sc (Critical Care) (UOFS), B Soc Sc (Nursing) (UOFS), BA Cur (/ et A) (UNISA), OECP, AEA 
School for Military Health Training 


ABSTRACT 


Deciding which patient to treat first when more than one patient requires medical 
treatment is a decision that must be made on scientific grounds. The use of 
evidence-based triage protocols could significantly help medical personnel in 
making the decision. 

Patients are prioritised into categories according to the life or limb threatening level 
of their injuries. The higher the category, the more severe the injuries and the more 
urgent the medical treatment required. 

Triage SIEVE is a model based on the mobility and ABC (Airway, Breathing and 
Circulation) presentation of the patient. This model is used to perform initial / 
primary triage and is presented in an easy-to-follow algorithm. 

Triage SORT takes into consideration anatomical and physiological parameters of 
the patient. Clinical knowledge and experience are important in the interpretation of 
the patient’s presenting signs and symptoms in order to make a decision. 

On the battlefield, reversed triage may be used. In this scenario, the patients with 
minor injuries are treated before patients with more serious injuries in order to return 
them to the battlefield. 



INTRODUCTION 


Triage was initially developed by Dominique Jean Larrey (1,5), a surgeon during the 
Napoleonic Wars (1803-1815). He realised that casualties must be sorted into priorities of 
care to optimise care without taking their military rank into consideration. His objective was 
however to treat the less injured first to get them back to battle as soon as possible. 

Triage existed in the past but only informally. It was only during World War I (5) (1914 — 
1 91 8)that formalised triage was initiated by French doctors who were treating the wounded 
on the battlefield as well as at the aid stations behind the front. 

Until recently, triage was frequently performed as a matter of “the best guess” based on the 
experience and perception of the triage officer as opposed to a meaningful assessment 
based on repeatable criteria. 

In the past, victims of war or casualties were prioritised according to three basic categories: 

• Those who are likely to live, irrespective of what care they are going to receive 

• Those that are likely to die, irrespective of what care they are going to receive 

• Those for which immediate care might have a positive outcome 

The modern-day approach in triage of casualties has become more scientific, based on 
scientific criteria and repeatable by different triage officers. Patients are now classified 
according to the following categories (4,5): 

PI: Critical: Those in need of immediate life-saving treatment. 

P2: Urgent: Those in need of medical treatment that can be delayed for a limited time 
period. 

P3: Minor: Those in need of minor medical treatment. 

P4 (PI Hold): Patients not salvageable with the resources available or who are so severely 
injured that they cannot be saved. 



Priority 2 - Serious 

Patients classified as Priority 2 (P2) are injured in such a way that they might require 
surgery or constant medical attention. The patient’s general condition, however, permits 
that if surgery is needed; it may be delayed for a couple of hours. Examples of injuries that 
would be as signed to a P2 category include, but are not limited to, large tissue wounds, 
fractures to the major bones, intra-abdominal or thoracic wounds or burns to less than 20% 
of the body surface area. Medical treatment such as splinting and pain control will be 
required (4). On average this priority represents 15% of the surviving casualties. In a colour 
coding system, this category is marked YELLOW or ORANGE. 

Priority 3 - Non-Urgent or Minor 

Patients classified as Priority 3 (P3) have minor injuries, the so-called walking-wounded. 
They do not require immediate life saving medical interventions. When colours are used to 
indicate the classification, P3 is indicated by GREEN. Examples of patients in this category 
include, but are not limited to, small burns, lacerations, abrasions and small 
fractures(4).This priority is on average the largest group of casualties and represents 75% 
of the surviving casualties 1 . 

Priority 4 (or PI HOLD) 

Patients classified as Priority 4 (P4)are so severely injured or moribund that their chance of 
survival is almost non-existent, given the resources available for their treatment (4,5). In 
some triage systems, the terms PI Hold or expectant are used to identify this category of 
patients. 

The P4 priority is the casualty who would have been a PI priority, if there were adequate 
resources available. However, with the P4 priority, the treatment of the patient cannot be 
initiated with the resources available at that moment in time. 

The P4 priority is activated to do “the greatest good for the greatest number of patients” 
taking into account the limited resources available. If more resources become available, 
any surviving P4 patients are immediately re-triaged to PI for immediate care (6). 


1 It is emphasised that the distribution of 10% Priority 1, 15% Priority 2 and Priority 3 75% are planning norms based on 
analysis of battlefield statistics. 



Patients in this priority must still be provided with comforting measures and pain medication 
and must be treated with the necessary respect (4). 

TRIAGE SIEVE 

The Triage Sieve method (Diagram 1) can also be referred to as primary or initial triage (5). 
Triage Sieve is used as an initial tool for the fast and simple prioritising of a large number of 
casualties simultaneously. 

Triage Sieve is a quick “first look” triage to prioritise the many casualties for care. Clinical 
interpretation on how the patient’s condition may change must not be taken into 
consideration. As the Sieve method is a simple procedural method of triage, the use of non- 
clinical personnel to perform Triage Sieve may be considered during this phase to optimally 
use clinical personnel to provide emergency interventions and execute more advance triage 
procedures. 

Triage Sieve is based on two fundamental principles: Mobility and the ABC (Airway, 
Breathing and Circulation). 

Mobility. 

The first step is determining the mobility of the patient. Patients that can still walk are 
prioritised as P3. It does not matter if the patient has a laceration, fracture, or any other 
injury. As long as the casualty is able to move/walk on his/her own he/she is prioritised as a 
P3 patient. The patient is immediately directed to the P3 treatment area. 

Should the patient be seriously injured, but able to walk he/she is still triaged as P3 at this 
stage and is directed to the P3 treatment area where skilled medical staff evaluates every 
patient using secondary triage methods. 



Airway and Breathing: 

The second step is to determine whether the casualty is breathing. If the casualty is not 
breathing, the airway is opened with simple airway manoeuvres such as chin-lift or jaw- 
thrust and breathing effort re-assessed. If breathing is absent, the patient is considered to 
be dead 2 . 

If breathing is detected once the airway is opened, the patient is prioritised as PI - airway 
problem. This patient is immediately transferred to the PI resuscitation area. 

For casualties who were breathing, the respiratory rate is used as a tool to determine 
effectiveness of ventilation. If the respiratory rate is below 9 or above 30, the casualty is 
prioritised as PI- breathing problem. This patient is immediately transferred to the PI 
resuscitation area. 

If the breathing rate is between 10 and 29, continue to the next step on the Triage Sieve 
algorithm assessing circulation. 

Circulation: 

The third step is to do an assessment of the circulatory status of the patient. Circulation is 
assessed by means of the pulse rate (radial). If the pulse rate is above 120, the casualty is 
prioritised as PI - circulatory problem. This patient is immediately transferred to the PI 
resuscitation area. 

Capillary Refill Time (CRT) can also be used as an indicator of the circulatory status, 
however, evaluating capillary refill time might be difficult in the combat scenario due to 
austere conditions. In the dark, sufficient light is needed to accurately assess capillary refill 
time. Switching on a light in the dark, austere battlefield environment will make the medical 
personnel immediate targets. Cold conditions and subsequent hypothermia also make CRT 
an unreliable indicator. Assessing CRT needs to be used with caution. . If the capillary refill 
time is longer than 2 seconds, the casualty is prioritised as PI - circulatory problem. 


2 It must be emphasised that Triage Sieve is used in the Major Incident or disaster situation where a large number of 
patients need to be assessed and prioritised in the shortest possible time. It is within this environment that the patient 
with an open airway that is not breathing is classified as dead. If more resources are available, the more advance Triage 
Sorting tool may be utilised. 



P2 ALLOCATION 

If all of the abovementioned criteria are within the normal limits of the algorithm, the 
casualty must be prioritised as a P2 priority and transferred to the P2 treatment area. P2 
patients therefore have a pulse rate of less than 120 beats per minute or a capillary refill 
time of less than 2 seconds. 

TRIAGE SORT 

Triage Sort (Diagram 2) is performed as the secondary triage (5). Triage SORT is thus 
performed when more resources, time and skilled personnel are available, such as at the 
stabilisation point, the Level 1 Resuscitation Post and at the Level 2 Field Hospital. Often, 
when a large group of patients arrive simultaneously, they are first triaged using the sieve 
method to get them into specific categories, then every category is revisited and the 
casualties re-evaluated using the more refined Triage Sort method. 

Diagnostic equipment (blood pressure monitors) must be available to aid in assigning triage 
priorities. 

Triage Sort is a physiological measure of the severity of the casualty’s injuries based on the 
following three parameters: Glasgow Coma Score, Respiratory rate and Systolic Blood 
Pressure. 

Step 1: Determine the Glasgow Coma Score of the casualty. 

Step 2: Determine the Systolic Blood pressure of the casualty. 

Step 3: Determine the Respiratory rate of the casualty and convert the respiratory rate to a 
value using the scale provided. 


Step 4: Assign a score according to the measured value for each physiological variable. 



s 

No 

Physiological 

Variables 

Measured Value 

Score 


A 

b 

C 

1 

Glasgow 

3 

0 


Coma Score 

4-5 

1 



6-8 

2 



9-12 

3 



13-15 

4 

2 

Systolic Blood 

0 

0 


Pressure 

<49 

1 



50-75 

2 



76-89 

3 



>90 

4 

3 

Respiratory 

0 

0 


Rate 

1-5 

1 



6-9 

2 



>30 

3 



10-30 

4 


Table 1 : Measured Values and Scores of Physiological Variables 


Step 5: Add up the allocated scores: Glasgow Coma Scale + Systolic Blood pressure + 
Respiratory Rate. (Note the original Glasgow Coma Score total is not added in but only the 
converted score is used) 




Step 6: Determine the triage priority according to the accumulative score. 


SNo 

Score 

Triage Priority 


A 

B 

1 

1-10 

Priority 1 

2 

11 

Priority 2 

3 

12 

Priority 3 

4 

1-3 

Priority PI Hold/ P4 

5 

0 

Dead 


Table 2: Triage Sort - Score and Triage Priority 


Step 7: Take into account anatomical and physiological aspects that may have an effect on 
the nature of the injury. The Triage Officer may use clinical judgement and assign a higher 
triage priority to the patient based on specific findings indicating the need for more urgent 
treatment of the patient. It must be emphasised that the use of clinical judgement to 
upgrade a patient’s triage priority must be based on observed findings and not on possible 
deterioration of the patient’s condition. For example, a walking casualty with facial burns 
may be heamodynamically stable and based on clinical findings be categorised as a Priority 
3 casualty, however, due to clear facial burns, singed facial hair and soot on the tongue, the 
patient requires intervention to maintain an airway and is therefore upgraded to a Priority 1 - 
airway patient. 

This action must, however, be used with great caution to prevent large numbers of 
casualties being upgraded to Priority 1 based on assumed possible complications and 
cluttering the emergency treatment capability. 

TRIAGE IN THE OPERATIONAL SCENARIO 

The choice of which triage system to use in the operational scenario will depend on the 
location and resources available (1). 

On the battlefield, triage takes place within an area with already limited resources. Triage 
determines if casualties should receive immediate treatment, eg application of a tourniquet 




to stop catastrophic bleeding, or whether transfer to the stabilisation point is possible. In this 
situation, Triage Sieve will be applied continuously and repeated at each point in the 
evacuation chain until the casualty reaches an area where a more refined triage method 
can be used. This is often only possible when the casualty reaches the Level 1 
Resuscitation Post. 

Basic principles that can aid in the triage process on the tactical battlefield environment are 
(4): 

1 . Movement of the casualty and attendant out of danger take precedence over a life saving 
procedure or other medical interventions. Casualties who are not clearly dead may be 
moved to cover, if possible, and / or on command of protection forces. 

2. Perform an initial rapid assessment of the casualty as soon as cover is reached. This 
assessment should not take longer than 60 seconds (1 minute) per casualty and includes 
Triage Sieve. 

3. Treat any life-threatening haemorrhages and perform life-saving interventions as 
needed. For example, to open airways, stop bleeding and stabilize injured limbs will save 
lives and reduce further injuries. Pressure dressings and tourniquets are very useful tools to 
prevent catastrophic bleeding, which is a major cause of deaths on the battlefield. 

Please take note that these principles apply to the combat scenario where there are limited 
resources. Care under fire poses a lot of challenges to the medical personnel, especially 
with haemorrhage control that takes priority. 

Initiating the Priority 4 (PI HOLD or expectant) category can be forced by the tactical 
situation. It is thus advisable to obtain sanction from the higher headquarters (HQ) to 
initiate the Priority 4 category at the Level 1 Resuscitation facility. The higher HQ is more 
aware of the complete tactical situation at hand and the possibility of receiving more 
resources. If more resources become available or, due to the tactical situation, no more 
patients will be arriving at the specific facility, all currently available resources can be used 
for the treatment of the patient. If, however, the higher head quarters are aware of a hostile 
action taking place with resulting large numbers of casualties, it may advise that the Priority 



4 category is used to free-up resources for additional casualties that are on the way. It must 
be emphasised that the decision to activate the Priority 4 category is seldom taken and 
must be based on a proper tactical appreciation of demand versus resources. 


The United States of America Marine Corps describe the principles of tactical / battlefield 
triage as follows (5): 

1 ) To accomplish the greatest good for the greatest number of casualties. 

2) To employ the most efficient use of available resources. 

3) To return personnel to duty as soon as possible (Reverse Triage). 


REVERSE TRIAGE 

In some situations the preservation of fighting power may be of utmost importance for the 
survival of the element. In these instances it might be necessary to treat less seriously 
wounded or injured before the severely wounded or injured casualties to get them back 
fighting. As the less injured are treated to the level that they can return to the fighting, 
efforts can then be redirected to the seriously wounded that will require all available 
resources to be treated. This concept is called reverse triage where Priority 3 casualties are 
treated/stabilise first to get them back fighting, then try to save the priority 1 and 2 
casualties. 

in certain scenarios, it might be of the utmost importance to direct the medical resources 
first towards the injured medical personnel as this may be advantageous to ensure that they 
survive to continue with the treatment of the injured soldiers / casualties. 

Triage is not a democratic decision-making process and requires very tough decisions in a 
very short time. The “return to battle” or a “fight to save the ship” is a tactical scenario that 
may take precedence over “best medical care practice” (1,2). The decision to initiate 
reverse triage can thus be forced by the tactical situation and not only by the clinical 
decision making process. 



RE-TRIAGE 


Triage is never a one-off process. It is repeated continuously at every link of the evacuation 
process and after each intervention. At arrival on the scene of a Ratel vehicle that was shot 
out by enemy fire, that has been declared safe by the fighting element, the medic will 
assess all casualties using Triage Sieve and allocate priorities. The team will then use 
these priorities to extricate the casualties from the vehicle to a stabilisation point. At the 
stabilisation point all casualties are re-triaged using Triage Sieve to determine their present 
condition to determine the need for intervention. After interventions, for example, inserting a 
naso-pharyngeal airway and applying a bomb bandage, the casualty is re-triaged as his/her 
condition may now be more stable. This process is repeated continuously. 

EVACUATION 

Two key factors must be considered in making a decision on the evacuation of a casualty to 
a higher level of care, namely the current triage priority and the required treatment^). 
These two factors are used to triage the casualties for evacuation. 

Triage Priority 

As indicated above, the patient must be re-triaged after receiving any form of treatment. 
Additional criteria must then be added to determine the evacuation priority. The triage 
priority alone may not be the sole determination for evacuation priority. The availability, type 
and capacity of vehicles are examples of additional criteria that must be kept in mind and 
added during the decision making process regarding the patient’s evacuation priority. If, for 
example, after initial treatment the patient is re-triaged and his/her priority has changed 
from P2 to P3, a sophisticated means of transport is not needed and his/her need for 
immediate transport to a higher facility is less urgent. The first available mode of transport 
may not be the appropriate mode for the specific casualty and the team may decide to 
evacuate the priority 2 casualties with the available ambulance and hold the priority 1 
casualty back for the helicopter confirmed to be landing within a few minutes’ time. The 
most appropriate means of evacuation must be used to ensure that each patient reaches 
the next level of care alive. 



Treatment 

The correct amount of treatment is necessary to ensure that the patient survives to the next 
level of care. According to the patient’s priority classification, treatment and packaging must 
be restricted to what is necessary for safe and effective evacuation. An unstable casualty 
results in an unstable evacuation. It may be indicated to hold back a higher priority to 
complete preliminary stabilisation while a lower priority casualty is evacuated first. 

Often the team is confronted with two or more casualties with the same triage priority, but 
only space to evacuate one casualty. In this type of situation, the criteria of who will benefit 
the most by the treatment at the next level of care must be considered as additional criteria 
to determine evacuation priority. 

Evacuation triage, therefore, not only uses Triage Sieve or Sort, but also considers the 
additional criteria of treatment requirement to determine the evacuation priority. 

CONCLUSION 

Casualties must be triaged at every link of the evacuation process (chain) as triage is a 
dynamic process and the casualty’s condition can deteriorate at any time, or improve after 
received treatment. 

Triage in the tactical situation is an art that requires situational awareness, decisiveness 
and clinical expertise. Each decision is driven by factors such as the personnel versus the 
casualty ratios, provider skills, accessibility of equipment, and the availability of evacuation, 
communication and supplies. Time, distance and weather may also play significant roles as 
do fatigue, confusion and panic(l). Triage Sieve provides the tool for scientific triage at this 
level. This can be done by any person available on scene. 

As soon as a casualty reaches more appropriate levels of care where more resources are 
available, a more detailed triage process can be used. Triage Sort provides the tool for this 
assessment, but requires clinical knowledge, equipment, time and capability to calculate 
scores. It is recommended that it is used from the Level 1 Resuscitation Post to the Level 3 
Specialist Hospital. 



The category of Priority 4 is a very specific category reserved for very specific situations 
where the need totally overwhelms the available resources and it is very seldom activated. 

Reverse Triage refers to a unique system to optimise treatment to preserve fighting power 
in a desperate battlefield situation. 

Evacuation Triage uses the same system but additional criteria are taken into account. 

REFERENCES 

(1) Baker M.S. Creating Order from Chaos: Part 1: Initial Care and Tactical Considerations in Mass Casuaty and Disaster 

Response. Military Medicine. 2007 March; 172(3): p. 232-236. 

(2) Baker M.S. Creating Order from Chaos: Part II: Tactical Planning for Mass Casualty and Disaster Response at 

Definitive Care Facilities. Military Medicine. 2007 March; 172(3): p. 237-243. 

(3) Janousek J.T., Jackson D.E., DeLorenzo R.A., Coppola M. Mass casualty triage knowledge of military medical 

personnel. Military Medicine. 1999 May; 164(5). 

(4) United States Marine Corps. FMST Student Manual. [Online].; 2008 [cited 2009. Available from: HYPERLINK 

"http://www.operationalmedicine.org/TextbookFiles/FMST_2008/FMST_1421.htm" 

(5) Advance Life Support Group. Major Incident Medical Management and Support: A practical approach at the 
scene London: BMJ; 2007. 

(6) Ligthelm T.J., Du Plessis H.J.C. Operational Trauma Treatment Algorithm. MILMED Scientific. 2008 February; 1(1): p. 


39-43. 



Triage SIEVE 



BREATHING 


NO 


OPEN 

AIRWAY 


BREATHING 



YES 



URGENT 
PRIORITY 2 


Diagram 1 : Triage SIEVE 








Recognition of airway compromise and the contributing factors are critical in 
deciding between the various basic options available to open the airway. The 
talk-look-listen-feel approach is taught world wide as part of evaluating a possible 
compromised airway as well as contributing factors. (1) Utilising basic airway 
manoeuvres is crucial in stabilising and opening the casualty’s airway initially. It 
is sometimes the only option available to a health care provider and sometimes it 
is the only manoeuvre necessary in stabilising the airway of the casualty. 

Talk to the casualty. An appropriate reply in a normal voice indicates a patent 
airway, sufficient breathing and adequate brain perfusion for that moment. Any 
inappropriate or incomprehensible response suggests a decreased level of 
consciousness, airway compromise, breathing compromise or all three. (1) 

Look for chest rise, obstruction/foreign bodies in the mouth and pharynx - any 
abnormal behaviour like agitation, confusion, drowsiness and signs of cyanosis 
can indicate oxygenation compromise. (1) 

Listen for any signs of breathing, any abnormal sounds. Partial obstruction of 
the larynx can produce snoring, gurgling (mostly liquid) and gargling sounds. 
Laryngeal injury and or swelling can cause hoarseness or stridor. (1) 

Feel for expired air which will indicate breathing attempts. Feel if the trachea is in 
the midline. Although this is a very late sign and should not be relied upon, it can 
indicate a possible tension pneumothorax (1). 

Any possible compromise should be addressed immediately to improve 
oxygenation and to prevent further deterioration of the casualty. 

Clearing of the airway: 

Visible foreign bodies can be swept out of the mouth with a gloved finger. A 
Magill’s forceps could also be used (if the object could safely be grabbed without 



pushing it deeper into the airway). Fluid like blood and secretions can safely be 
suctioned under vision with a rigid suction tip (2). Suction devices will only 
become available once the casualty is transferred from the battlefield. 

Vomitus however can not be suctioned away quickly enough before the casualty 
needs to take another breath. During vomiting, the casualty should be turned on 
his/her side while maintaining inline stabilisation of the neck to allow clearing of 
the airway, whether suction is available or not. 

Rolling onto the side / Recovery Position: 

If a casualty is breathing on his/her own with signs and symptoms indicating 
sufficient oxygenation, the casualty can be turned on his/her side to keep the 
airway open. In a trauma casualty, the logroll method is preferred due to a 
potential neck injury but can only safely be done when enough rescuers are 
available. One rescuer provides inline stabilisation of the head and neck of the 
casualty. The rest of the rescuers then help to turn the casualty as a unit under 
direction of the rescuer at the head. 

The airway has priority over the C-spine. Open the airway as soon as possible 
with the safest method, however, if no other rescuers are available and logroll 
cannot be done; the breathing casualty should be turned on his side (potentially 
risking a spinal injury) 

Chin lift: 

The chin lift (without head tilt) is safe to use in a potential neck injury. The 
forefingers and thumb are used to lift the chin upwards and the thumb can also 
open the mouth by gently pressing on the chin/lower lip. The rescuer can 
stabilise the head by putting his/her other hand on the casualty’s forehead 
( 1 , 2 , 3 , 4 ). 



The head tilt; chin lift manoeuvre can only be used in the casualty without any 
possible spinal trauma. 


Jaw thrust: 

The mandible is displaced upwards and forwards with both thumbs on the 
casualty’s zygomas and the index and middle fingers under the angle of the 
mandible. (1) 



Figure 1: Jaw thrust (From: BATLS Manual 2006 Edition) 


Barrier devices: 

Assisted ventilation can be achieved by mouth-to-mouth ventilation, but the fear 
for contracting communicable diseases makes this an unattractive option. 
Commercial devices that minimize this possibility exist in the form of barrier 
devices like face shields. The pocket mask with a one-way valve can also be 
used to minimize the risks and oxygen supplementation can be used with this 
method. A barrier device should be part of the buddy aid kit on every soldier’s 
bag. These techniques are not safe if a chemical agent vapour hazard exists. (1) 



Bag-mask ventilation: 

A bag-valve-mask (BVM) or resuscitator bag can be used to assist ventilation in 
a casualty with poor oxygenation. This technique can be performed by one or two 
rescuers, with the two rescuers being the preferred method, especially if the one 
hand (or one rescuer) technique is not providing adequate oxygenation. 
Adequate bag mask ventilation is usually evident with chest expansion and 
clinical improvement in the patient. (3,5) If oxygenation is not optimal with the 
bag or the chest not rising, check for mask seal (eg KY gel on a bearded patient 
or reinserting casualty’s false teeth or place gauze inside the mouth to create a 
more anatomical mask seal), rule out a foreign body in the airway, check jaw- 
thrust manoeuvre effectiveness, release cricoid pressure (if used), all possible 
upper airway adjuncts already in use or ask a more experienced person to 
perform manoeuvre (5,6). 

Supplemental oxygen with a reservoir bag can give inspired oxygen 
concentrations of >90% if the reservoir bag is not deflated during ventilation and 
a good seal is provided. (6) 

Oropharyngeal airway: 

The oropharyngeal airway (Guedel type or OPA) is only used in casualties 
without a gag reflex and stops the tongue from falling back by inserting it over the 
tongue. The preferred insertion method is to direct the airway concavity over the 
tongue after the tongue has been pressed out of the way with a tongue 
depressor. The old method of inserting the airway concavity upwards until the tip 
reaches the soft palate and then rotate it 180°, slipping it into place over the 
tongue can cause damage to the soft palate and will only be recommended if no 
tongue depressor can be found (eg laryngoscope blades, teaspoon, small branch 
etc) (5,7,8). 


Nasopharyngeal airway: 



The nasopharyngeal airway provides oxygen to posterior pharynx and can be 
used in a casualty with a gag reflex. Correct sizing is important and 
measurement extends from the nares to the trachus/earlobe (adjust safety pin if 
necessary) and the diameter of the inside aperture of the nares (1 ,4,5,7). Assess 
for obvious nasal passage obstruction before insertion and lubricate the airway 
well. Insert the tip into the nostril and direct it posteriorly towards the ear with a 
slight rotation motion until the safety pin rests against the nostril. Epistaxis can 
occur in up to 30% (9) of cases, but direct pressure will usually be enough to stop 
the bleeding. 



Figure 2: Oropharyngeal airwaysFigure3: Nasopharyngeal airway Figure 4: Partial rebreather 


Supplemental oxygen masks: 

Supplemental oxygen should be provided to any casualty as soon as it becomes 
available, but due to the scarce availability on the battlefield, it should be used on 
the casualty with the greatest need for oxygen (see TCCC guidelines table 1). If 
a casualty is breathing on his/her own and does not need assisted ventilation 
with a BVM, an oxygen mask will deliver supplemental oxygen safely. The partial 
rebreather mask can produce inspiratory oxygen percentages of 60% and higher 
owing to a reservoir bag (which should never deplete during ventilation). 
(4,5,8,10,11) 

ADVANCED AIRWAY MANAGEMENT 

An advanced airway device should be used if the above basic airway 
manoeuvres and devices cannot obtain sufficient oxygenation and ventilation. A 




vast amount of different advanced airway devices are available on the market 
and it is the health care provider’s responsibility to decide which device would be 
best in the different circumstances and according to his/her scope of practice. On 
the battlefield, it is sometimes better to place an advanced airway in a 
compromised airway before moving on to the next casualty - it is easier for a 
fellow soldier to quickly learn how to squeeze a bag than to ventilate the casualty 
with a mask. (12) 

Endotracheal intubation: 

The only safe airway is a cuffed tube in the trachea because it prevents 
aspiration. A properly placed endotracheal tube whether orally or nasally and a 
properly placed surgical airway, whether it be a cricothyroidotomy or 
tracheostomy, are thus the only safe airways. 

The endotracheal tube is a cuffed, single-use tube placed through the vocal 
cords which allows delivery of high flow oxygen and selected tidal volume to 
maintain adequate ventilation. (7) This technique usually needs sedative and 
neuromuscular-blocking agents to facilitate smooth intubation as is done in rapid 
sequence intubation (RSI) unless the patient is deeply unconscious. Medication 
for RSI will only be available at the resuscitation post.(3) Good preparation and 
anticipation of a possible difficult airway is critical in planning for the intubation. 
(13) Indications for intubation would be to obtain and maintain an open airway, to 
protect the airway, to correct inadequate oxygenation and ventilation and to 
intervene early because of the predicted clinical course. (8,13) A full description 
of the steps in RSI is beyond the scope of this article. Tracheal intubation should 
only be attempted after proper training and after gaining extensive experience 
because doing it wrong can turn an injured casualty into a dead casualty. 

Clinical confirmation (usually subjective signs) of correct tube placement would 
be to see that the tube goes through the cords (the best proof)(1 3), auscultation 



of chest, chest rising, vapour in the tube (seldom) and clinical improvement of 
cyanosis. 



Figure 5: Endotracheal intubation (From BATLS manual 2006 edition) 

Commercial devices (usually objective signs) are the only really objective proof of 
correct placement. The oesophageal detector device (EDD) and exhaled CO 2 
detection devices are both available and both can be used at all levels of care. 
(5,6,8) The principle behind the oesophageal detector device use is the collapse 
of the oesophageal walls if negative pressure is applied to the endotracheal tube 
and in the trachea this does not happen. It comes as a 60cc catheter tip syringe 
or a rubber bulb(better success rates). After intubation, it is attached to the 
endotracheal tube. If the plunger stays out with negative pressure, it implies 
correct tube placement. If the deflated bulb attached to the endotracheal tube 
inflates immediately/quickly, it implies correct tube placement. A few situations 
can prohibit the safe use of these devices but overall they have a very high 
success rate. Exhaled CO 2 can be measured with single use inexpensive 
devices available and is rapidly becoming a standard of care in the emergency 
airway management (13). The device is placed in-line at the endotracheal tube 
connector and the presence of C0 2 will be indicated by a colour change. The 
specificity of the exhaled C0 2 is 97-100% and the positive predicted value 100% 
(4,5,6,8,10) and therefore it should be part of the medical officer’s bag as the 
primary confirmation device. (13) 




Figure 6: Oesophageal detector device Figure 7: C02 Detector device 

Securing the endotracheal tube after verifying correct placement is also of critical 
importance. Commercial devices to secure the tubes are widely advocated in all 
studies and textbooks owing to its high prevention rates of accidental tube 
displacement compared to traditional methods like tape and tie. (5,10,11,15) A 
commercial device to secure the endotracheal tube should therefore also be part 
of the medical officer’s bag. 

Endotracheal intubation can be difficult, especially in the challenging conditions 
encountered in the emergency setting, and a few airway tips can help with those 
difficult situations. Changing the blade of the laryngoscope to a longer blade 
(usually the problem) or a different type of blade, eg a straight blade might help. 
Positioning the tip of the blade differently eg directly elevates the epiglottis, or 
indirectly lifting the epiglottis by placing the tip of the blade in the vallecula might 
provide a better view. Optimise the position of the casualty by putting his/her 
head at the end of the bed and increase the stretcher height to prevent bending 
of the back while intubating (head at belly button of rescuer). The laryngoscope 
should be lifted along the long axis of the handle and a helper can help with the 
traction on the handle. An endotracheal stylet should be used with every 
intubation to help with tip placement. External laryngeal manipulation during 
direct laryngoscopy will improve glottic exposure. It is pressure applied by the 
rescuer intubating as backward, upward and rightward pressure (BURP) until 
visualization of the vocal cords. Another helper can then take over the exact 
pressure while the intubation is attempted. A bougie can be utilised, especially in 
situations where the vocal cords cannot be visualised but only the tip of the 




epiglottis (Grade 3 Cormack-Lehane). A bougie should be readily available 
before any intubation attempt to be used immediately if the view causes any 
trouble. (5,6,8,14) 



Figure 8: Adult and paediatric bougie 


Pulse oximetry can be used to monitor a casualty’s oxygen saturation, or 
actually, the percentage haemoglobin saturated with oxygen. It does not 
measure oxygen tension or alveolar ventilation but is useful in detecting 
unsuspected hypoxemia. It has been used with huge success in the battlefield 
conditions and during transfer to monitor the shocked casualty and to evaluate 
the result of resuscitation efforts. Hand held models are an ideal option on the 
battlefield. (13,15) 

ALTERNATIVE INTUBATION TECHNIQUES 

Alternative intubating techniques should be used if difficult intubation is 
encountered. A difficult intubation can be defined as a situation where the 
rescuer had more than two attempts with the same blade, a change of blade or a 
bougie was used without success and use of an alternative device or technique 



was necessary. Alternative intubation techniques would include the Trachlight®, 
the intubating laryngeal mask airway (ILMA) or the LMA-Fastrach® and an 
indirect fibreoptic device like the Glidescope or Airtraq®. 

The intubating laryngeal mask airway (ILMA) or the LMA-Fastrach® is a shorter, 
stainless steel barrel laryngeal mask which allows intubation owing to a 
prominence at the junction of the mask and barrel which directs the flexible, re- 
enforced endotracheal tube centrally and anteriorly. It is only available in sizes 
for casualties from 30kg and heavier. Successful insertion and ventilation occur 
in > 95% of cases and is invaluable in situations with bad vision due to fluid 
accumulation in the pharynx. (5,6,8,13) 

The Glidescope is an indirect fibreoptic device usually only used for training 
purposes due to financial reasons. The Airtraq® is a new, single use, indirect, 
fibreoptic device available in SA and relatively inexpensive. The endotracheal 
tube is attached to the device before insertion and a series of mirrors deliver an 
image to the proximal eyepiece. (5,6,8) Early studies on manikins show exciting 
figures but any excessive fluid in the pharynx can lead to poor visibility and 
difficulty in placing the endotracheal tube through the vocal cords. The latest 
studies show clearly that the Airtraq provides superior intubating conditions in the 
difficult laryngoscopy scenarios and has a rapid learning curve. (17,18,19,20) 

The ILMA / LMA-Fastrach and the Airtraq should be available at the Level 1 
resuscitation post as well as at all higher levels of care. The ILMA or Fasttrach 
will assist in intubating when a clear view due to secretions / fluid is not possible. 
The single use version is cheaper and will be ideal in the battlefield. The Airtraq 
will assist with intubating when visualisation is a problem (eg due to inability to 
manipulate the position of the patient to extend the neck). 




Figure 9: Intubating LMA Figure 10: Airtraq Figure 11: Airtraq loaded 

SUPRAGLOTTIC DEVICES 


The supraglottic devices are utilised in the failed airway situation where three 
attempts at endotracheal intubation (including an alternative technique/device) 
failed. Some of the supraglottic devices currently available in SA are the 
laryngeal mask airway (LMA), the LMA Supreme, LMA Proseal, the oesophageal 
tracheal Combitube and the King Laryngeal Tube. These devices do not secure 
the airway, but it might help and buy time in ventilating/oxygenating the casualty 
while waiting for a more senior rescuer and/or waiting to transfer the casualty to a 
higher level of care. A supraglottic device should be available in the emergency 
care bags on the battlefield for rescue ventilation. 

The laryngeal mask airway (Classic) was first introduced in 1988 and is well 
known and widely used in SA and single-use devices in a full range of sizes are 
also now available. Application does not need direct visualisation of the vocal 
cords as well as no additional equipment like a laryngoscope but it needs good 
airway anaesthetisation or deep sedation, e g Ketamine titration would be an 
excellent choice.(5,6,8) 

The LMA Supreme is a single-use laryngeal mask airway newly introduced which 
has the following features: Modified cuff allowing higher airway pressures, a 
proximal bite block and a second lumen for oesophageal drainage. The latter 
makes it an ideal choice for the emergency casualty. This is as the classic 



laryngeal mask airway easily used by inexperienced personnel which is a further 
advantage for use in the emergency casualty. (5,6,8,21) 

The oesophageal-tracheal Combitube is currently losing favour as a supraglottic 
device due to newer and cheaper devices available. The King Laryngeal tube is a 
new tube with exciting features. It is either reusable or disposable and adult and 
paediatric versions are available. It has two cuffs inflated simultaneously as well 
as a separate gastric drainage channel. The latter is again the exciting feature of 
the laryngeal tube as well as its ease of insertion and its success rate of 97- 
100%. (5,6,8,21 ,22) In studies done under Army Combat Medic students the King 
Laryngeal tube had a success rate of 100% (96% in the Combitube) and was 
inserted in half the time compared to the Combitube. (24,25) 

At this stage the LMA Supremeor the Laryngeal tube would be an excellent 
choice as a supraglottic device on the battlefield. It will thus be used as a rescue 
device in the cannot intubate / cannot oxygenate casualty just before a surgical 
option is tried. 





Figure 12: LMA Classic Figure 13: Combitube Figure 14: Laryngeal Tube 


SURGICAL AIRWAY 


Usually, the last resort in the failed intubation/failed oxygenation (cannot intubate; 
cannot oxygenate) is the surgical route. The cricothyroid membrane is usually the 
area utilised for the surgical airway owing to its ease of location and it is relatively 
avascular compared to the more distal areas. 




Needle cricothyrotomy is falling out of favour due to its limitations in effectiveness 
and safety. Jet ventilation provides more effective ventilation than low flow 
oxygen (15 litre/min) due to its higher pressures achieved but also causes more 
barotrauma and is not readily available in the emergency setting due to the 
financial implication. (5,6,8) 


Surgical cricothyrotomy places a tube into the trachea via the cricothyroid 
membrane and it can either be done as an open procedure or via a Seldinger 
technique (more expensive). A vertical skin incision is followed by a horizontal 
incision through the membrane. A horizontal incision can also be made through 
both the skin and membrane simultaneously. A small tracheostomy tube (5-6 
mm) or small endotracheal tube (size 5-6 mm cuffed tube) is inserted and 
secured. (5,6,8,26) 




Figure 15: Surgical Cricothyrotomy (From: BATLS Manual 2006 Edition) 

TACTICAL COMBAT CASUALTY CARE 

The Tactical Combat Casualty Care(TCCC) project started in 1993 after the need 
for trauma care guidelines in the tactical settings was recognised. Principles and 
guidelines in this project have been incorporated into the Prehospital Trauma Life 
Support (PHTLS) course and it is endorsed by the American College of 



Surgeons’ Committee on Trauma and the National Association of Emergency 
Medical Technicians. (27) 


The Tactical Combat Casualty Care (TCCC) project has identified three phases 
of care on the battlefield as Care under Fire - care rendered by the medic on the 
scene, Tactical Field Care - care given by medic when he and the casualty is no 
longer under hostile fire and Tactical Evacuation Care - Combat Casualty 
Evacuation Care is care rendered once the casualty has been picked up by an 
aircraft, vehicle or boat. The three goals of TCCC are: Treat the Casualty, 
Prevent Additional Casualties and Complete the Mission. (27) 

Tactical Combat Casualty Care Guidelines have been suggested by the TCCC 
projectin 1996 and revised in 2003, 2006 and 2009. These guidelines for 
effective airway management in the different phases of care in the battlefield are 
highlighted in table 1 . 


Care under Fire phase: 

• Airway management is generally best deferred until the Tactical Field 
Care phase. 


Tactical Field Care phase: 

• Unconscious casualty without airway obstruction: 
o Chin lift or jaw thrust airway manoeuvres 

o Nasopharyngeal airway 
o Recovery position 

• Casualty with airway obstruction or impending obstruction 
o Chin lift or jaw thrust airway manoeuvres 

o Nasopharyngeal airway 

o Allow the conscious casualty to assume position that best protects the 
airway even sitting up 






o Recovery position in the unconscious casualty 

• If above measures fail: 

o Surgical cricothyrotomy (lignocaine if conscious) 

Tactical evacuation Care phase: 

• Unconscious casualty without airway obstruction 
o Chin lift or jaw thrust airway manoeuvres 

o Nasopharyngeal airway 
o Recovery position 

• Casualty with airway obstruction or impending obstruction 
o Chin lift or jaw thrust airway manoeuvres 

o Nasopharyngeal airway 

o Allow the conscious casualty to assume position that best protects the 
airway even sitting up and recovery position for the unconscious 
casualty 

• If above measures fail: 

o Laryngeal mask airway / intubating LMA or 
o Combitube or 
o Endotracheal intubation or 
o Surgical cricothyrotomy (lignocaine if conscious) 

• Spinal immobilization is not necessary for casualties with penetrating 
trauma 

• Most combat casualties do not require oxygen, but may be beneficial in 
following types of casualties: 

o Low oxygen saturation by pulse oximetry 
o Injuries associated with impaired oxygenation 
o Unconscious casualties 

o TBI casualties (maintain oxygen saturation > 90) 
o Casualties in shock 
o Casualties at altitude 

Table 1: 2009 Tactical Combat Casualty Care Guidelines (xxvii) 




In a study done on 6 875 prehospital combat casualties between Jan 2005 and 
March 2007 (Operation Iraqi Freedom), advanced airways were use in 293 
(4.2%) of the casualties and 97.3% (282) were trauma casualties. The advanced 
airways were 86.6% (253) endotracheal intubations, 7.5% (23) received 
supraglottic devices and 5.8% (17) received surgical cricothyrotomies. (28) 

CONCLUSION 


Management of the airway in a casualty can be a stressful event in any working 
environment and the previous paragraphs described airway management in the 
ideal world and work environment. On the battlefield, austere conditions are 
usually encountered like bad light, extremes of temperature, noisy etc; equipment 
might be depleted and/or not available and the casualty can either be lightly 
injured or critically ill. The rescuer can just be a fellow soldier or a highly trained 
health care provider but both can be tired/hungry/frightened and their level of 
care would depend on their coping skills as well as previous training. 

The health care providers on the battlefield should be proficient in managing the 
airway of the casualty during all phases of the combat care and have access to 
the equipment to do so. Training of these individuals should be done on a 
constant basis and it should include also all the new developments available out 
there to save the lives of their casualties. 

REFERENCES 

(1) Dippenaar T.A. et al. South African Military Health Service Battlefield Advance Trauma Life 

Support Manual. 2 nd ed. 2000. 

(2) Salomone J.P. et al. Prehospital Trauma Life Support Military Edition. 6 th ed. 2007 Mosby 

Jems. 

(3) Krantz B.E. et al. Advanced Trauma Life Support for Doctors. 6 th ed. 1997. 

(4) Jacobs B.J., Hyot K.S. Trauma Nursing Core Course Provider Manual. 5 th ed. 2000. 



(5) Kovacs G., Law J.A. Airway Management in Emergencies. 1 st ed. 2008 McGraw Hill 

Medical. 

(6) Walls R.M., Murphy M.F., Luten R.C., Scheider R.E. Manual of Emergency Airway 

Management. 2 nd ed. 2004 Lippincott Williams & Wilkins. 

(7) Lynch M. et al. American Heart Association Airway Management Student guide. 1 st ed. 
2007 

American Heart Association. 

(8) Kovacs G. et al. The South African Airway Interventions & Management in Emergencies. 

4 th 

ed. 2005 University of the Witwatersrand. 

(9) Hazinski M.F. et al. American Heart Association Guidelines for CPR and ECC. Supplement 

to Circulation, volume 112, 2005. 

(10) Field J.M. et al. Advanced Cardiovascular Life Support Resource Text for instructors and 

Experienced providers. 1 st ed. 2008 American Heart Association. 

(1 1 ) Zimmerman J.L. et al. Fundamental Critical Care Support. 3 rd ed 2002 Society of Critical 

care Medicine. 

(1 2) Middleton T.A. Lessons from the Battlefield. Wow technologies and techniques proving 

themselves in combat care may benefit patients of civilian EMS. EMS Magazine Oct 2009 
Issue. 

(13) Marx et al. Rosen’s Emergency Medicine, Concepts and Clinical Practice. 7 th ed volume 1, 

2009. 

(14) Caplan R.A. et al. Guidelines for difficult airway management. /4naesf/72003;98:1 269-77. 

(15) Beilman G., Blondet J.J. Near-infrared spectroscopy-derived tissue oxygen saturation in 

battlefield injuries: a case series report. WJ Emerg Surg 2009;25:4-25. 

(16) Shai L. Proposed technique for evaluation of endotracheal tube fixation and comparison of 

four fixation methods. Mil Med Jan 2001. [cited 2009, Oct 17] Available from: 
http://findarticles.eom/p/articles/mi qa3912/is 2001 01 /ai n8936716/ 

(1 7) Tong J.L. The Airtraq - the ideal indirect device for the Defence Medical Services. JR Army 

Med Corps 154;1 :78. 

(18) Basaranoglu G., Suren M., Teker G.M., OzdemirH., Saidoglu L. The Airtraq laryngoscope 
in 

severe ankylosing spondylitis. JR Army Med Corps 1 54;1 :77-78. 

(19) Missaghi M.S. et al. The Airtraq Optical Laryngoscope: experiences with a new disposable 

device for orotracheal intubation. Internet J Airway Management 4; 2006-2007. [cited 
2009, Oct 17] Available from: 

http://www.adair.at/iiam/volume04/clinicalinvestiaation02/default.htm 


(20) Maharaj C.H., Costello J.F., Higgins B.D., Harte B.H., Laffey J.G. Learning and 
performance 

of tracheal intubation by novice personnel: a comparison of the AIRTRAQ and Macintosh 
laryngoscope. Anaesthesia 2006;61 :671-7. 

(21 ) Calkins M.D., Robinson T.D. Combat trauma airway management: endotracheal intubation 

versus laryngeal mask airway versus combitube use by Navy SEAL and Reconnaissance 
combat corpsmen. J Trauma 2000;26:362-3. 

(22) Hagberg C., Bogomolny Y., Gilmore C., Gibson V., Kaitner M., Khurana S. An evaluation of 

the insertion and function of a new Supraglottic Airway Device, the King LT™, during 
spontaneous ventilation. Anesth Analg 2006;102:621-5. 

(23) Guyette F et al. King Airway use by Air Medical Providers. Prehosp Emerg Care 2007;1 1:1- 

4. 

(24) Cain J.S. From the Battlefield to our streets. How combat medicine is revolutionizing 

civilian prehospital care, [serial online] 2008 Oct 1. [cited 2009, Oct 17] Available from: 
http://.iems. com/resources/supplements/the war on trauma/from the battlefield to our 
streets.html 

(25) Hill G., McManus J., Schwartz R., Ward J., Holcomb J. Supraglottic devices in tactical 
airway 

management: A comparison of the King Laryngeal Tracheal device and the Combitube in 
army combat medic students, [cited 2009, Oct 17] Available from: 
http://www.allacademic.com/meta/p61 91 6 index.html . 

(26) Macdonald J.C. Homer C N, Tien M D. Emergency Battlefield Cricothyrotomy. CMAJ 

2008; 178: 

(27) The Office of the Division Surgeon. 2009 Tactical Combat Casualty Care Guidelines, [cited 

2009, Oct 17]. Available from: http://www.itstactical.com/2009/07/10/20Q9-tccc- 

quidelines/ 

(28) Adams B.D., Cuniowski P.A., Muck A., De Lorenzo R.A. Registry of emergency airways 

arriving at combat hospitals. J Trauma 2008;64:1548-54. 


Basic Mechanical Ventilation in the Operational 
Theatre 


Maj P.J. van Aswegen 

M SocSc(Critical Care) (UOFS), BSoc Sc(Nursing) (UOFS), BA Cur (let A) (UNISA), OECP,AEA 
School for Military Health Training 


ABSTRACT 


Mechanical ventilation in the austere conditions of the operational theatre could 
proof intimidating to the inexperienced health care professional. By creating an 
easy-to-follow flow diagram, basic mechanical ventilation should be achievable 
and safe, even during austere conditions. 

In order to mechanically ventilate a patient, three settings should be applied, 
namely percentage of oxygen (or fraction of inspired oxygen (Fi 02 )), a breathing 
rate (frequency) and a volume (Tidal Volume (V T )). The tidal volume administered 
to a patient must be calculated according to the patient’s ideal weight. 

After initiating the initial settings, care must be taken to ensure proper oxygen 
delivery by adding positive end expiratory pressure (PEEP), if necessary, and 
reducing the peak inspiratory pressure (PIP) to less than 30 cmH 2 0. 

By using general guidelines for mechanical ventilation, inexperienced health care 
personnel could safely and successfully ventilate patients, even in austere 
conditions. 


INTRODUCTION 



Fear of mechanical ventilation due to a lack of knowledge or lack of exposure and 
experience should not scare off Health Care Professionals and should not prevent the 
patient from receiving this type of treatment. 

The operational theatre, or battlefield, represents austere conditions where the 
inexperienced health care professional could potentially withhold the application of a 
mechanical ventilator due to uncertainty. The result is that the intubated patient will 
need manual bag ventilation that requires the constant attention of scarce resources, 
namely personnel, and could lead to over- or under inflation of the patient’s lungs. 

The aim of this article is to familiarise the inexperienced health care worker with the 
basic principles of mechanical ventilation. The focus is thus on the normal healthy 
soldier, G1K1 classified, that was injured and required intubation. The mechanical 
ventilation initiated is also for short-term use (24 hours or less) only and the patient 
should be transported to a higher care facility as soon as possible. The mechanical 
ventilation of children and complicated ventilatory patients, such as asthma and COPD, 
is beyond the scope of this article. 

OPERATIONAL VENTILATORS 

Operational ventilators make use of positive pressure to ventilate the patient. This 
means that positive pressure is applied to the patient’s airway and this causes flow of 
gas into the lungs until the ventilator breath is terminated. Patient exhalation occurs as 
the airway pressure drops to zero, and elastic recoil of the chest then pushes the tidal 
volume out (1). 

To enable the ventilator to deliver the positive pressure to the patient, the ventilator will 
either need a pressure source or a compressor. 



• The pressure driven ventilators need a pressurised oxygen source in order to 
function. The ventilator does not contain a battery and will thus function as long 
as the pressure supplied by the oxygen source is enough to drive the ventilator. 

• The internal compressor ventilator has its own compressor and can function 
without the use of additional oxygen. The ventilator does, however, contain a 
battery and the ventilator will stop when the battery runs flat. If no additional 
oxygen is needed one can ventilate the patient as long as enough battery power 
or charging facilities are available. For additional oxygen, the same facilities as 
the pressure driven ventilator are required. 

The choice of ventilator will thus depend on operational circumstances and the 
availability of logistical support. For example, on the battlefield it is not advisable to 
carry pressurised oxygen and the ventilator with an internal compressor will be more 
advantageous, whereas the pressure driven ventilator could be more useful at the 
resuscitation post where enough oxygen is available and higher oxygen concentrations 
are required. 

INITIAL VENTILATOR SETTINGS 

Before any settings on the ventilator are made, one needs to determine the ideal weight 
of the patient. This is essential, since all ventilator settings are according to the 
patient’s ideal weight (2). An easy to remember “rule of thumb’’ is that the ideal weight 
for a 1 .7 metre tall patient is about 70 kg and for a 1 .8 metre tall person it is about 80 
kg, etc. 

In order to ventilate the patient, three basic variables should be present, namely 
oxygen, frequency and volume. If one is able to deliver these three variables to the 
patient, the patient is being ventilated. Consider the following variables: 


Fraction of Inspired Oxygen 



The Fraction of Inspired Oxygen (Fi0 2 ) can also be translated to the percentage of 
oxygen that is delivered to the patient. The fraction refers to the total out of one (1 ), and 
percentage to the total out of 1 00. An oxygen percentage of 40% is thus the same as a 
Fi0 2 of 0.4. 

Normal room air contains 21% oxygen (3). Ventilating a patient without additional 
oxygen would thus deliver 21% oxygen to the patient. 

The oxygen percentage (or Fi0 2 ) delivered to a patient can be adjusted on the 
ventilator. Normal adjustments can vary from 21% (room air) up to 100%. Depending 
on the make of ventilator available, there could either be a dial, knob or a switch that 
can be turned to select the desired oxygen percentage,. If the ventilator has a switch, 
the choice of oxygen percentage delivered is severely limited. The standard options are 
“No Air Mix/Air Mix” or “45%/100%”. 

The initial Fi0 2 setting should be 1.0 (100% or ”No Air Mix”). If the patient maintains a 
Sp0 2 above 92%, the Fi0 2 can be titrated down to 0.5 (50% or “Air Mix”)(2). 

When using a ventilator, care should be taken to note the setting of the Fi0 2 (or the 
0 2 %) on the ventilator. This setting should also be documented when performing vital 
sign measurements. 

Frequency 

Breathing Frequency (Freq) refers to the number of breaths the patient receives in one 
(1) minute. The normal range of breathing frequency for a healthy adult is 12-20 
breaths per minute(4). For the purpose of remembering the basics for ventilation, a 
normal breathing frequency will be taken as 10 breaths per minute. The set frequency 
of the ventilator should also be noted during vital sign measurements. 


Tidal Volume 


The Tidal Volume (Vj) is the volume of air entering or leaving the lungs during a single 
breath (5). The usual recommendations for V T levels are 8 to 10 ml/kg (2). For the 
purpose of remembering the basics for ventilation under austere conditions, a value of 
lOml/kg will be used. A patient that weighs 70 kg will thus receive a Vj of 700 ml 
(lOml/kg x 70 kg = 700 ml). 

The tidal volume delivered to a patient can be adjusted on the ventilator. Depending on 
the make of ventilator available, the dial used to adjust the V T will indicate either V T or 
V M . The V M indicates Minute Volume. 

The Minute Volume (V M ) indicates the volume of air entering or leaving the lungs during 
one minute. The V M is calculated by multiplying the V T with the Frequency, for example, 
if a patient receives 10 breaths per minute and a V T of 500 ml, then his/her V M is 5 litres 
(10 breaths/minute x 500 ml V T = 5000 ml V M = 5 I V M ). 

The primary determinant of CO 2 exchange during mechanical ventilation is known as 
alveolar minute ventilation (V A ). Alveolar minute ventilation is calculated by subtracting 
the volume of anatomic dead space (the volume of the conducting passages in an adult 
that average about 150 ml) (V D ) from the V T and then multiply the value with the 
frequency [V A = (V T - V D ) x Freq] (2,5). This is important to show that when the VT is 
increased, the entire increase goes toward elevating the alveolar ventilation, whereas 
an increase in respiratory rate (Freq) does not go entirely toward increasing alveolar 
ventilation (5). A respiratory rate of only 10 breaths per minute could thus be safely 
used with a tidal volume of 10 ml/kg. 


The initial ventilator settings are thus as follows: 

Oxygen percentage = 1 00% (Fi02 = 1 .0) 

Frequency = 10 breaths per minute 
Tidal Volume = 10 ml/kg 




The above settings are easy to remember, even if a person has not used a ventilator for 
a long period of time. If the ventilator does not have a Tidal Volume (V T ) setting, but 
only a Minute Volume (V M ) setting, one only has to set the V M according to the patient’s 
weight, for example, a patient that weighs 80 kg will have a V M of 8 litres and a patient 
that weighs 90 kg will have a V M of 9 litres. 

ADDITIONAL CONSIDERATIONS 

By administering the three basic variables, namely oxygen, frequency and volume, the 
patient is being ventilated. The question is now, ‘what other parameters should a 
person keep in mind?’ 

Inspiratory pressure 

During positive pressure ventilation, airway pressure rises progressively to a peak 
pressure, which is reached at the end of inspiration. Peak pressure is also called peak 
inspiratory pressure (PIP) or peak airway pressure. This pressure is the sum of two 
pressures: the pressure required to overcome airway resistance and the pressure 
required to overcome the elastic properties of the lung and chest wall (2). 

On most ventilators one will notice two important airway pressure-related controls: 

The first is the maximum pressure setting knob. The maximum pressure allowed 
during inspiration can thus be set. Depending on the ventilator, the maximum value can 
differ from 15 cm H 2 0 up to 80 cm H 2 0. The PIP should ideally be maintained at <30 
cm H 2 0. Adverse effects from high inspiratory pressures include barotrauma, 
volutrauma and reduced cardiac output (2). In order to ensure that the patient is 
protected against the negative effects of high inspiratory pressures, one should not set 
the maximum peak inspiratory pressure to exceed 40 cm H 2 0. Should the patient’s PIP 
reach 40 cm H 2 0, the ventilator will stop delivering the breath, thus protecting the 
patient from the negative effects of high inspiratory pressures. An alarm will also sound 
to warn the health worker that a problem has occurred and that his/her immediate 
attention is needed. 



The second control a person might find on the ventilator is a pressure gauge. On the 
gauge one can note the PIP and record the value together with the vital signs. 

Elevated inspiratory pressures may be reduced by the following interventions (2): 

• Decreasing Positive End Expiratory Pressure (PEEP) - this action may decrease 
oxygenation 

• Decreasing the V T - this action may increase C0 2 levels in the blood 
(Hypercapnia) 

• Ensure that the ventilator tube and endotracheal tube are not obstructed 

One’s decision to lower the PIP should thus be regarded in accordance with the 
condition of the patient. When poor oxygenation, inadequate ventilation or excessively 
high peak inspiratory pressures are thought to be related to the patient’s intolerance of 
ventilator settings and are not corrected by adjusting the ventilator, consider sedation 
and the use of analgesia (2). 

Expiratory Pressure 

As humans exhale, a certain amount of air remains in their alveoli and is called the 
functional residual capacity (FRC) (5). This remaining volume creates a pressure inside 
the alveoli that keeps the alveoli from collapsing. This pressure is called the Positive 
End Expiratory Pressure (PEEP) (2). 

On the ventilator PEEP is a mode that involves the maintenance of positive pressure at 
the end of expiration, rather than allowing the airway pressure to return to atmospheric 
pressure as usually occurs. By maintaining the positive pressure, alveoli that would 
otherwise collapse, are held open, thus increasing the opportunity for gas exchange 
across the alveolocapillary membrane. This is accomplished by increasing the FRC. 
The result is a decrease in physiologic shunting and the ability to achieve a higher level 
of Pa0 2 with lower concentration of delivered Fi0 2 (6). If the patient is already on 100% 



oxygen and his/her saturation is still below 90%, one can start to increase the PEEP in 
order to raise the patient’s Sa0 2 . 

PEEP can, however, be hazardous because of the increased intrathoracic pressure. 
The most important side effects of PEEP are 6 : 

• An increased incidence of pneumothorax 

• Reduction in venous return - this is especially important in dehydrated or 
hypovolemic patients. A raise in Intra Cranial Pressure (ICP) could also be 
experienced due to the decreased venous return. 

On the ventilator PEEP can be set if the ventilator is advanced enough to have the 
function, or by adding a PEEP valve to the expiratory part of the ventilator circuit. The 
PEEP valve has a knob that can be turned to select the amount of PEEP offered. 

Because of the dangers involved with using PEEP, the indications for operational use of 
PEEP should be limited to patients that are unable to maintain their Sp0 2 above 92% 
on 100% oxygen. A PEEP of 5 cm H 2 0 should then be started and increased with 1 cm 
H 2 0 increments until a maximum of 10 cm H 2 0 is reached. It is important to remember 
that by applying PEEP, one will also increase the patient’s PIP and the risk for 
barotrauma. The administration of PEEP should thus also be limited to ensure that the 
patient’s PIP is maintained below 30 cm H 2 0. 

CHANGING SETTINGS 

Even when conducting basic mechanical ventilation, the need may arise to change 
some of the settings. The question is when and how to make changes to the ventilator 
settings. For basic mechanical ventilation in the operational theatre, the flow diagram 
can be used (Diagram 1): 

You already know how to set the initial settings for the ventilator and we will now focus 
on changing those settings. These settings need to be checked together with each vital 



sign measurement and charted. Continuous adjustments (after each vital sign 
measurement) may also be needed. 

The aim of mechanical ventilation is to improve gas exchange and thus increase the 
patients Pa0 2 . Since the measuring of Pa0 2 in the operational theatre is unpractical, 
we will firstly focus on the patient’s Sa0 2 . Is the patient’s Sa0 2 more than 90%? 

• If the answer is ‘NO’, one will need to address the problem. Firstly, ensure that 
the patient is receiving 100% oxygen. If this is already the case, start to 
administer PEEP. 

• If ‘YES’, then one can start to wean the patient to a Fi0 2 of 0.5 (50%) or less. 

The second parameter that needs attention and possible intervention is the patient’s 
peak inspiratory pressure (PIP). Is the PIP 30 cm H 2 0 or less? 

• If ‘NO’, reduce the tidal volume (V T ) and simultaneously increase the breathing 
frequency in order to maintain the minute volume (V M ). For example, a frequency 
of 10 with a V T of 500 ml has the same V M as a frequency of 15 with a V T of 333 
ml, namely V M = 5 litres. The PIP generated by the V T of 333ml is, however, 
much less than that of the Vj of 500ml. 

• If ‘YES’, no further steps need to be taken. 

CONCLUSION 

Mechanical ventilation of an injured patient in the operational theatre should not prove 
to be a complicated and unsustainable procedure. The use of general guidelines to 
help the inexperienced health care professional could help improve the quality of care, 
improve patient outcome and reduce mortality. 

Knowing the make and the capabilities of the available equipment and regular practice 
would also be beneficial to enhance the confidence of the health care professional as 
well as the patient outcome. 



The availability of compressed oxygen and the logistical maintenance of an adequate 
reserve on the battlefield and resuscitation post are not plausible. It is thus advisable 
that the ventilator that functions on an internal compressor be used during these 
conditions. The pressure-driven ventilator is more advantageous at the field hospital 
setting where logistical support is available. 


REFERENCES 

(1) Wright J., Doyle P., Yoshihara G. Mechanical Ventilation: Current Uses and 

Advances. In: [publication unknown], [Printer unknown]; page 262-288. 

(2) Society of Critical Care Medicine. Fundamental Critical Care Support. Third Edition. 

United States of America: Society of Critical Care Medicine; 2001. 

(3) Zumdahl S.S., Zumdahl S.A. Chemistry.Sixth Edition. New York: Houghton Miflin 

Company; 2006. 

(4) American Academy of Orthopaedic Surgeons. Basic Emergency Care and 

Transport of the Sick and Injured. London: Jones and Bartlet; 2005. 

(5) Sherwood L. Human Physiology: from cells to system. Sixth Edition. USA: 

Thomson Brook/Cole; 2007. 

(6) Phipps W.J, Cassmeyer V.L., Sands J.K., Lehman M.K. Medical Surgical Nursing: 

Concepts and Clinical Practice. Fifth Edition. New York: Mosby; 1991. 




Diagram 1 : Basic Mechanical Ventilation in the Operational Theatre 


© Maj P.J. van Aswegen 
August 2009 


1 


Haemostatic Technologies to Control Bleeding on 
the Battlefield 


Col H. J. C. Du Plessis, sm, mmm 

MB ChB (UP), M MED(SURG), FCS(SA), FACS 
Chief Surgeon: SAMHS and 1 Military Hospital 
Adjunct Professor of Surgery, School of Medicine 
Faculty of Health Sciences, University of Pretoria 


ABSTRACT 


Haemorrhage remains the most common cause of preventable mortality on 
the battlefield. Basic measures that could be used by everyone to control 
bleeding which include local pressure, adding a dressing of some sort 
(bomb bandage, pressure dressing, etc), applying pressure to pressure 
points and elevation of a limb are highlighted. This is substituted by the 
development of the so-called haemostatic dressings. These dressings 
stimulate clotting and can be used in areas where basic measures or a 
tourniquet is inappropriate or cannot be used. These products have been 
tested extensively for use with the military in operational situations. 
Different haemostatic agents are discussed indicating the various 
physiological mechanisms utilised to control bleeding. 

Tourniquets were used extensively in previous wars and have again been 
proven to save lives if used correctly, but can be dangerous if used 
incorrectly. 

The article demonstrates that effective haemostatic dressings available on 
the market can control bleeding from most wounds, and some can also 
prevent infection. 



2 


INTRODUCTION 

Haemorrhage remains the most common cause of preventable mortality on the 
battlefield. Buddy aid was developed and taught to all troops to try and reduce 
this cause of mortality, but the activities remain very basic, namely local pressure 
to stop the bleeding, and adding a dressing of some sort (bomb bandage, 
pressure dressing, etc). When this is inadequate, applying pressure to pressure 
points and elevation of a limb can be added for control. Another adjunctive used 
on the battlefield is the tourniquet, which is very effective to stop bleeding if 
applied correctly, but training is necessary to achieve this. When the tourniquet is 
applied incorrectly, or not tight enough, it only constricts the venous return, 
leading to more bleeding. This is also only useful with extremity injuries, where a 
tourniquet can be applied. 

A rather serious injury involving the groin (as was depicted in the movie Black 
Hawk Down) led to the development of the so-called haemostatic dressings. 
These stimulate clotting and can be used in areas where a tourniquet is 
inappropriate or cannot be used. These include QuikClot, TraumaDex (Arista), 
Celox, Hemcon, WoundStat, X-Sponge, etc. Most of these were developed in the 
USA on the request and funding of the US Military, and tested under strict 
scientific guidance and all seem to work in stopping the bleeding. 

The experimental model (1 ,2, 3, 4, 5) for testing all of these bandages is to create 
a severe groin injury in the pig where the groin is incised, transecting the femoral 
artery and vein totally or partially, allowing bleeding for a period of time (to 
simulate the operational situation) allowing the blood pressure to drop to around 
40 mm Hg, then applying the dressing and resuscitating the animal to a mean 
blood pressure of around 60 mm Hg. Blood loss is measured before and after 
application of the dressing, and the end point of the study is survival for 3 hours, 



3 


which is the duration of the study. These were done by different investigators in 
different laboratories at different times, and were funded by different departments 
of the military. As can be expected, the results also differ, and the protocols were 
adjusted in time to accommodate some of the critiques on the model. One of the 
first models (1) where a complete transection of the vessels was done, the 
dressing with the best survival was Quikclot. This is dehydrated Zeolite granules 
that generate heat when exposed to fluids and blood, concentrating the clotting 
factors and platelets leading to haemostasis. The heat generated could also lead 
to haemostasis per se as this could stimulate the blood vessels to contract and 
stop bleeding (as was done ages ago with hot irons and hot oil poured into 
wounds). The Zeolite was later modified by making it less dehydrated to generate 
less heat (QuikClot 1 st Response Advanced Clotting Sponge), but it seems as if 
the new product is not as potent to control bleeding as the original one, but it is 
safer, as the heat generated is much less and therefore the surrounding tissue 
damage also less. 

HAEMOSTATIC AGENTS 

QUIKCLOT 

This was one of the earliest products passed for use by the US military, and has 
been utilized in operational circumstances in Iraq and Afghanistan. It consists of 
Zeolite, a volcanic rock substance, broken down to granules of around 2-3 mm, 
which is sterilized and dehydrated when packaged. It is extremely hygroscopic, 
and generates heat when it comes into contact with water and blood. The 
rationale for its effectiveness is that by absorbing water, the clotting factors and 
platelets are concentrated to give rise to a strong and effective clot to control the 
bleeding. The heat generated can reach 70 to 80 degrees C and can be 
damaging to the tissues in the vicinity of the injury. To reduce the heat generation 
the Zeolite dressing is modified by dehydrating it to a lesser degree (called 
QuikClot 1 st Response) and also packaged in a bag (like a large tea bag) to 



4 


simplify the handling. It is not as effective in stopping the bleeding as the original 
product. 

The latest product out of the QuikClot stable (Z-Medica, Newington, CT, USA) is 
the QuikClot combat gauze and QuikClot emergency dressing. These are gauze 
dressings impregnated with Kaolinite (a white alumina silicate clay material) that 
stimulates clotting by activating the clotting mechanism directly. The gauze 
dressing is applied directly over the bleeding wound with compression to control 
bleeding until the patient can be seen in an emergency department. 



Figure 1 : QuikClot First Response granules 

TRAUMADEX and ARISTA 

This product (Arista) has been on the market for a while as an adjunct to 
haemorrhage control during surgical operations. It consists of microporous 
polysaccharide hemispheres, which are small granules that absorb fluid from the 
bleeding site, concentrating the clotting factors to stimulate and accelerate the 
clotting cascade. It does not generate heat in the process. When the need for a 
pre-hospital haemorrhage control dressing or substance was identified, the 
product was marketed as TraumaDex. It is a white powder that can be poured 
directly into the wound. The price was also reduced, which led to the selective 


5 


use of the TraumaDex rather than Arista, after which the company ( Medafor, 
Minneapolis, MN, USA) took TraumaDex off the market. 



HEMCON 

This product has also been tested extensively (1 ,2,4,5) and is in use with the 
military in operational situations. Hemcon is a gauze dressing impregnated with 
chitosan, an extract of polysaccharide made from shrimp shells with haemostatic 
properties. This dressing becomes extremely adherent when in contact with 
blood, and this seals the wound and controls the bleeding. It can be placed on 
the wound, or stuffed into the wound. The mechanism of action includes platelet 
activation, vasoconstriction and interactions with red blood cells through ionic 
forces and cell surface proteins. A side effect that was found is the antibacterial 
properties (6) of the chitosan. It is effective against most of the common 
organisms found in war wounds, like MRSA, other Staphylococci, Streptococci, 



6 


and gram negatives like Pseudomonas, Acinetobacter, Serratia, Proteus, 
Enterobacter, Citrobacter, Moraxella, Stenotrophomonas, Salmonella, Shigella, 
etc. This makes it very effective in areas where evacuation is suboptimal, as the 
antibacterial effect prevents the development of infection in the wound, and 
second look and debridement can be postponed for a while. It is used extensively 
by the U S Army (7)during deployment. It is distributed by HemCon Inc, Portland, 
OR, USA. 




<§g) HEMCON 
HemCon® Bandage 

(Chitosan, 4 " x 4 ") ^ 

Training Sample 
Instructions for use: 

1 ' A PP'y dressing directly over actively bleeding wound with tan 
backing away from wound. 

2. Apply pressure to the backing for up to 2 minutes, or longer if 
required for dressing to adhere and bleeding to stop 

3. Apply outer bandage wrap (not included) to secure dressinq 
on wound site. 

4. Remove dressing within 48 hours. 

Cautions / Warnings: 

For external use only Do not implant. Do not eat 
Not for consumption. Single use only. Do not resterilize. 

Do not apply over eyes Contains chitosan from shellfish 
i Do not use if seal is broken and/or content is wet 
I Use promptly after opening. 


8M6015 Rev 


Figure 3: HemCon Bandage 


CELOX 

This is another of the products available for haemorrhage control. It consists of 
chitosan, the same complex carbohydrate polymer extracted from the shells of 
crustaceans, and the mechanism of action is similar to HemCon. It stimulates the 
formation of a strong clot without generating any heat in the process. It is 


7 


marketed as a powder that can be poured into the wound, and then covered with 
a dressing or bandage. It is manufactured and distributed by SAM medical, 
Newport, OR, USA. 



■TmiLi ] m 


i TE** ***** __ TEAR HERE ^ 

CELOX 

Hemostatic Granules 

CONTROLS MODERATE-TO-SEVERE BLEEDING 
PROMOTES RAPID COAGULATION 
Temporary Traumatic Wound Treatment 

NO HEAT GENERATED IN USE! 

== WORKS IN HYPOTHERMIC CONDITIONS 
CLOTS HEPARINIZED BLOOD 


QAM mboical 

I V I PWOOUCTB« 

<90® S COAST HWY STE 245. NEWPORT. OR 97365 

800 618 4726 / 541 867 4726 (USA) WWW SAMMEDJCAl COM 

PATENTS PENDING 

Stott • Unteu pouch a or open 

NET WT 0 5oi/ 15g 

FOR EMERGENCY EXTERNAL USE 

INSTRUCTIONS FOR USE ON BACK 


Figure 4: CELOX granules 


My opinion is that the latter 2 products are the most effective and safest to use by 
our troops on deployment, as well as in the civilian pre-hospital environment. 


TOURNIQUETS 


Tourniquets have been used extensively in previous wars and also in the civilian 
sector. Tourniquets can save lives if used correctly, but can be dangerous if used 
by the untrained. If applied incorrectly, it can lead to increased bleeding when 



8 


only venous pressure is exceeded in stead of arterial pressure. It can also lead to 
limb loss if kept on too long and distal ischemia develops, and uncontrolled 
release can lead to renal failure when a large load of myoglobin is released from 
the ischemic muscle. The ideal tourniquet should be applicable with one hand 
and should be effective in controlling bleeding from any extremity, both large and 
small. 

The popularity of tourniquets has varied through the ages and mostly finds 
popularity in conflicts as a way to control bleeding under fire, saving lives and 
buying time to evacuation of the injured. It is part of doctrine and training in most 
military forces (8,9,10,11,12) but mentioned as a last resort in the civilian pre- 
hospital scene as well as the ICRC (International Committee of the Red Cross) 
(13,14). 

The current recommendations regarding the use of tourniquets are the following: 
(15,16) 

a. Try all other means stop haemorrhage, including direct pressure and 
pressure dressings. 

b. If field conditions preclude other methods to control bleeding, use a wide 
tourniquet. 

c. Use padding under the tourniquet, to avoid skin and soft tissue damage. 

d. When applying a tourniquet, avoid the impulse “to do it partly”, because it 
should be fully applied, with high enough pressure to completely occlude 
arteries and arterial bleeding. 

e. Record in an obvious place (eg forehead) on the patient that a tourniquet 
is in place, and the time it was applied. 

f. Ensure that others along the chain of evacuation know that a tourniquet 
has been applied. 

g. Avoid covering up a tourniquet in an unconscious patient. 

h. Remove the tourniquet at the very first opportunity, preferably under 
surgical control. 



9 


Tourniquets come in a variety of forms and prices, and were previously evaluated 
(17, 18, 19). The TK4 tourniquet is a simple 6 cm wide rubber band with a metal 
hook that can be applied with one hand to control bleeding. A more complex (and 
expensive) type is the MAT (Mechanical Advantage Tourniquet), with a ratchet 
type mechanism to tighten the strap. In between is the CAT (combat application 
tourniquet) with a windlass to wind the strap to the right pressure to control the 
bleeding. This can also be applied and tightened with one hand. 



Figure 5: TK4 Tourniquet 


The TK 4 tourniquet is the one currently in use by our troops and medics while 
the CAT is available in some pre-hospital situations, special forces and the USA 
military. 



10 



Fig 6: CAT (Combat Application Tourniquet) 

TORSO WOUNDS 

All the above techniques are applicable to extremity wounds encountered on the 
battlefield. The torso can be (partially) protected by body armour, but some areas 
are still exposed and can lead to injury by penetration. These body wounds 
cannot be managed with superficial measures and still need surgery (and 
sometimes emergency surgery) to control the bleeding from a chest wound with 
injury to lung or blood vessels in the chest, or from an intra-abdominal organ 
injury (8,9,11,12). 

HIFU (HIGH INTENSITY FOCUSED ULTRASOUND) 

Ultrasound has been in use in medicine for a few decades, mostly in a diagnostic 
field. The transducer (or probe) sends a low frequency sound wave that gets 
reflected back from different organs, creating an image. When this sound wave is 
focused and intensified, it generates heat in a very small area, and this can 



11 


control the bleeding in that area by tissue coagulation. Injuries in blood vessels 
(20) and solid organs like spleen (21) and liver (22) have been sealed with HiFU 
under experimental conditions. If this process can be refined, theoretically 
injuries to the torso can be treated percutaneously with HiFU, without having to 
operate on patients under emergency conditions. One problem currently is to 
integrate the diagnostic and therapeutic transducers into one piece of equipment 
that can be used commercially, as it is very important to be able to see where the 
injury is and to focus the high intensity beam on the correct area of bleeding to 
be able to control it. This technology, however, is still some time off in the future. 

CONCLUSION 

Prevention of injury is still the best measure to control bleeding. If a soldier does 
get injured, there are very effective dressings available on the market that can 
control the bleeding from most wounds, and some can also prevent infection. 
Wounds to the body or torso still need emergency surgery for control of bleeding, 
but some developments are taking place that may in future be applicable in the 
battlefield. HiFU has some exciting applications, if the transducers can be 
modified to be user friendly under operational circumstances. 

REFERENCES 

(1) Pusateri A.E., McCarthy S.J., Gregory K.W., Harris R.A., Cardenas L., McManus A.T., 
Goodwin C.W. Effect of a Chitosan-based Haemostatic dressing on blood loss and survival in a 
model of severe venous haemorrhage and hepatic injury in swine.J Trauma.2003; 54:177-182. 

(2) Alam H.B., Uy G.B., Miller D., Koustova E., Hancock T., InocencioR., Anderson D., Llorente 
O., Rhee P. Comparative analysis of haemostatic agents in a swine model of lethal groininjury.J 
Trauma.2003; 54:1077-1082. 

(3) Kheirabadi B.S., Edens J.w., Terazzas I.B., Estep J.S., Klemcke H.G., Dubick M.A., Holcomb 
J.B. Comparison of new haemostatic granules/powders with currently deployed haemostatic 
products in a lethal model extremity arterial haemorrhage in swine.J Trauma.2009; 66:316-328. 



12 


(4) Kheirabadi B.S., Scherer M.R., Estep J.S., Dubick M.A., Holcomb J.B. Determination of 
efficacy of new haemostatic dressings in a model of extremity artetial haemorrhage in swine. J 
Trauma.2009; 67: 450-460. 

(5) Arnaud F., Parreno-Sadalan D., Tomori T., Delima M.G., Teranishi K., Carr W., McNamee G., 
McKeague A., Govindaraj K., Beadling C., Lutz C., Sharp T., Mog S., Burris D., McCarron R. 
Comparison of 10 haemostatic dressing in a groin transaction model in swine. J Trauma.2009; 
67:848-855. 

6 Burkatovskaya M., Tegos G.P., Swietlik E., Demidova T.N., Castano A.P., Hamblina M.R. Use 
of chitosan bandage to prevent fatal infections developing from highly contaminated wounds in 
mice. Biomaterials. 2006; 27: 4157-4164. 

7 Wedmorel., McManus J.G., Pusateri A.E., Holcomb J.B. A special report on the chitosan- 
based haemostatic dressing : Experience in current combat operations. J Trauma.2006; 60:655- 
658. 

8 Treatment of hemorrhagic shock. Battlefield Advanced Trauma Life Support incorporating 
Battlefield Advanced Resuscitation Techniques and Skills (BATLS-BARTS) Manual, Second 
Edition 2000. School for Military Health Training, Thaba Tshwane. 

9 Lounsbury D.E. Haemorrhage control, in Emergency War Surgery, Third United States 
Revision. Borden Institute, Walter Reed Army Medical Center, Washington, DC. 2004; 6. 3-6.4 

10 Kirby N.G. Initial Care of the Wounded, in Field Surgery Pocket Book. Her Majesty’s 
Stationary Office, London. 1983;21. 

11 Care under fire, in Pre-hospital Trauma Life Support (PHTLS), Military Edition. Sixth Edition. 
Mosby, Elsevier, St Louis Missouri, USA.2007; 502. 

12 Ligthelm T., Du Plessis H.J.C. Operational Trauma Treatment Algorithm. Milmed Scientific. 
2008; 1 : 39-43. 

13 Applying a Tourniquet, in Bleeding. AmericanAcademy of Orthopedic Surgeons’ Emergency 
Care and Transportation of the Sick and Injured, Seventh Edition. Jones and Bartlett Publishers, 
Boston, USA. 1999; 547-548. 

14 Life-saving techniques, First Aid in armed conflicts and other situations of violence, 
International Committee of the Red Cross, Geneva, 2006, 169. 

15 Welling D.R., Burris D.G., Hutton J.E., Minken S.L., Rich N.M. A Balanced approach to 
tourniquet use: Lessons learned and relearned. J Am Coll Sur 2006; 203: 106-115. 

16 Protocol for tourniquet application, in Shock. Pre-hospital Trauma Life Support (PHTLS) 
Military Edition. Sixth Edition. Mosby, Elsevier, St Louis Missouri, USA.2007; 182, and 505-510. 

17 Calkins M.D., Snow C., Costello M., Bentley T.B. Evaluation of possible battlefield Tourniquet 
Systems for the far forward setting. Mil Med 2000; 1 65: 379-384. 

18 Wencke J.C., Walters T.J., Greydanus D.J., Pusateri A.E., Convertino V. A. Physiological 
Evaluation of the U S Army One-handed tourniquet. Mil Med 2005; 170: 776-780. 



13 


19 Lakstein D., Blumenfeld A., Sokolov T., Lin G., Bssorai R., Lynn M., Ben-Abraham R. 
Tourniquets for haemorrhage control on the battlefield: A 4 Year Accumulated Experience. J 
Trauma 2003; 54: S 221 -S 225. 

20 Vaezy S., Martin R.W., Yasiji H.et al. Hemostasis of punctured blood vessels during high 
intensity focused ultrasound. Ultrasound Med Biol. 1998; 24: 903-910. 

21 Noble M.L., Vaezy S., Keshavarzi A. et al. Spleen hemostasis using High intensity 
Ultrasound: Survival and Healing. J Trauma.2002; 53: 1115-1120. 

22 Vaezy S., Martin R.W., Schmiedl U. et al. Liver hemostasis using high intensity focused 
ultrasound. Ultrasound Med Biol. 1997; 23:1413-1420. 



1 


Vehicle Extrication on the Battlefield 

ColT.J. Ligthelm 

MPA (UFS), B Soc Sc (Hon) (UFS), H Dip Ed (PCE), Dip Adv Nurs (UNISA), AEA, BARTS, Nat 

Judge Vehicle Extrication 

Senior Staff Officer Strategy and Plan 


LtColR.McQueen 

OECP, BARTS, BMR 

School for Military Health Training 


Maj P.J. van Aswegen 

M Soc Sc (Critical Care) (UFS), B Cur (letA) (UNISA), BARTS, OECO, AEA 
School for Military Health Training 


Maj H.S. Havenga 

OECO, BARTS, PHTLS, EMT-P 
School for Military Health Training 


Capt A. Motilal 

N Dip (Emer Med) (DUT) 

School for Military Health Training 


ABSTRACT 


Battlefield extrication can be defined as utilising the sequence of standard 
vehicle extrication to remove a life salvageable casualty from a battle 
vehicle in battlefield conditions. 

This requires adapting the principles of extrication to achieve effective 
extrication from an armoured vehicle using tools and equipment not 
primarily meant for extrication in a hostile enemy environment during 



2 


mobile warfare. Where in standard extrication procedures the vehicle is 
considered expendable, the vehicle in battlefield extrication is a weapon 
platform that needs to be optimally conserved. The material used for the 
construction of battle vehicles makes the use of standard cutting and 
spreading techniques and tools inappropriate. 

This article will apply the sequence of extrication to battlefield 
circumstances and summarise the recommended techniques for the main 
battle vehicles utilised by the South African National Defence Force. 


INTRODUCTION 

The mobility of modern warfare stems from the use of various types of battle 
vehicles to serve as weapon platforms, to transport soldiers and protect crew 
through armour and other designs. These vehicles, however, hold unique 
challenges when extricating casualties if it has been involved in an incident 
causing the entrapment of casualties. 

Extrication is defined as the safe and efficient freeing of persons from entrapment 
in land-based vehicles of all types(l). This concept is critically important on the 
battlefield where casualties can be trapped in any of the various battlefield 
vehicles due to numerous reasons. The most obvious is the destruction of the 
inner structures of a battle vehicle due to an explosion caused by various forms 
of explosive devices inside the vehicle. Further causes include the destruction of 
the structure of the vehicle by the energy transfer from an external explosive 
device such as an improvised explosive device (IED) positioned on the roadside 
and detonated in the close vicinity of the vehicle. However, vehicle crashes and 
incidents such as a roll-over from high ground can all cause entrapment of 
casualties inside a battle vehicle. 



3 


Although explosive device incidents within the close confines of a battle vehicle 
are often fatal, life casualties may survive and need to be extricated as soon as 
possible. Extricating the bodies of fatally injured crew may also entail extrication. 

An integral part of extrication is the disentanglement of the casualty from his or 
her entrapment by using various extrication techniques and equipment. 
Disentanglement is defined as that part of vehicle extrication that relates to the 
removal and/or manipulation of vehicle components to allow a properly packaged 
victim to be removed from the vehiclel). Sometimes referred to as “removing the 
vehicle from the victim ”(1). It is this aspect of extrication that holds serious 
challenges for the rescuer on the battlefield. 

BATTLEFIELD EXTRICATION 

The basic sequence of vehicle extrication or rescue is summarised by various 
authors using different terminology, but, if consolidated(1)(2),it can be 
summarised asfollows: 

• Size-up of the scene; 

• Hazard control; 

• Vehicle stabilisation; 

• Initial and sustained patient access; 

• Disentanglement; 

• Patient packaging; 

• Extrication; 

• Patient transport; and 

• Scene termination. 


If this chronological process is analysed, the challenges of battlefield extrication 
become apparent. 




4 


The South African Army uses various types of vehicles as weapon platforms, 
transport, protection and support vehicles in landward defence warfare. For the 
purpose of this article, only the basic armour platforms will be discussed since 
the transport vehicles are fairly standard heavy trucks used in a unique role. 

SCENE SIZE-UP 

Scene size-up is described by Moore(2) as an information gathering activity 
through which responders survey and assess the overall emergency scene. A 
circle survey is described as the resulting determination of an extrication strategy 
to initiate the necessary measures to handle the situation. On the battlefield this 
process is often initiated by a command request for support elements to move 
forward in the battle configuration to support a specific vehicle. This radio 
message is often very vague, merely indicating that a vehicle with a specific call 
sign has been shot out. 

The response is three-fold: firstly, all-round defence is established, then a 
medical support element moves forward and a technical support element is 
called forward. Because of battle configuration, the medical section is normally 
fairly close and can reach the scene within a short time span, while the technical 
support element lies further back and takes some time to reach the scene. This 
will, however, totally depend on the battle situation. If the target is not secure, 
reaction will need to be held back until own forces had fought through to the 
objective, after which the two support elements can move forward to manage the 
scene. 

On arrival, scene size-up can only start when all-round defence is in place, which 
is normally the deployment of infantry elements in a semi-circle around the scene. 
On approaching the battle vehicle, its own weapon systems are the immediate 
threat. Control over these systems may not be functional because internal 
destruction may result in the uncontrolled firing of a main weapon such as a 



5 


canon. For this reason, approaches must be from behind and out of the firing 
range of the weapon systems. The survey can then be executed in a semi-circle 
only in order not to cross the firing range of the weapon. This may be jeopardised 
by secondary weapons pointing in alternative directions, further limiting the “circle 
survey”. 



Fig 1 : Scene Size-Up indicating the Danger Area during the Circle Survey in line 
with the Weapon Systems (Note: This is only a diagrammatical representation 
and additional danger areas may exist due to secondary weapon systems) 


HAZARD CONTROL 


6 


Hazard control on the standard extrication scene includes, amongst others, 
identifying hazardous material, risks and unstable structures, and activating the 
necessary response such as the fire-brigade. In analysing hazards in a battlefield 
scene, this is not that simple. As already highlighted, the uncontrolled firing of 
weapons is a big threat, but sudden enemy actions may hold a similar risk. 
Unexploded ammunition in the vehicle holds a further challenge besides the 
standard hazards of leaking fuel and fire risks. The responders are totally 
dependent on the soldiers of the element involved to deactivate or safeguard 
weapon systems before attempting to manage the scene. 

The risk of a sudden offensive action by the enemy must not be under estimated. 
Enemy elements fire at anything that moves on the battlefield, so a rescuer 
becomes an automatic target not withstanding all Conventions(3) protecting 
medical personnel. It is not realistic to expect the enemy to recognise a 15 cm 
diameter red cross armband at a kilometre distance as a sign of protection. 
Therefore, parking vehicles on a battlefield scene as a protective shield against 
enemy fire is just as important as parking the ambulance as a shield against 
oncoming traffic on a standard freeway scene. The use of brightly coloured 
reflective garments, neon colour cervical collars and day-glow orange head- 
blocks is not a warning tool as in civilian extrication, but becomes a target for a 
sniper in the battlefield situation. 

Managing risks such as leaking fuel and possible fire is limited to pre-positioning 
of dry power extinguishers from the support vehicles in strategic positions and 
using sand to cover fuel. It is clear that a second hit by an explosive round from 
the enemy in this situation may wipe out the total responder group. 


VEHICLE STABILISATION 



7 


Stabilising the damaged vehicle is aimed at preventing any sudden and 
unexpected movement of the vehicle(l). In standard extrication this entails 
cribbing and shoring the vehicle to prevent any movement during extrication. 

Although it may be considered that a battle tank or armoured car is a very stable 
vehicle, this may not be the case. The vehicle may have been thrown onto its 
side Due to a roadside explosion, while a heavy battle vehicle travelling over 
uneven ground may slide or even roll-over into very unstable positions. 
Stabilising a 56 000 kg battle tank hovering over the side of a bridge or a 17 000 
kg Ratel on its side is a challenge. 



Fig 2: Unstable Battle Vehicle (picture: xmb.stuffucanuse.cpm/xmb/viewthread.php?tid=3591) 


8 


There is no standard stabilisation equipment available on the battlefield to 
execute the task, and cribbing is not part of the standard set of battlefield 
equipment. Stabilisation can only be achieved by using the equipment on the 
standard recovery vehicle as well as the other battle vehicles. A few basic chocks 
are available as base blocks used under hydraulic jacks. Rescuers must 
therefore improvise using bottle-type hydraulic jacks and base blocks to try and 
achieve stabilisation. Additionally, the winch system and cables of a recovery 
vehicle can be used to partially stabilise a battle vehicle, taking all safety 
elements of cables under load into account. Anchor points may be extremely 
limited, especially on the savannah or desert battle terrain. The best way of 
anchoring an unstable heavy battle vehicle is often to attach it to a second similar 
or bigger battle vehicle to partially stabilise it, for example, to use a tank to 
anchor an unstable tank. The use of a chain saw (which is part of the standard 
recovery vehicle’s equipment) in an applicable terrain to fell trees for cribbing is 
an option. As the functionality of the battle vehicle as a weapon platform needs to 
be preserved, standard drills such as to deflate the tyres to settle the vehicle on 
cribbing, are not recommended as it will jeopardise the vehicle’s capability to 
move once the casualties have been removed and an enemy counter-action 
occurs. This requires the training of Technical Support Personnel in vehicle 
stabilisation and vehicle safety. 

As soon as basic stabilisation has been achieved, and considering the weapon 
systems, access to the vehicle must be obtained. 

INITIAL AND SUSTAINED PATIENT ACCESS 

Gaining initial access to a standard vehicle is normally achieved with controlled 
glass removal after using a standard spring-loaded punch. On the battlefield, 
gaining vehicle access is limited to using the available hatches, as it is 
impossible to gain access through armoured steel or armour-plated glass using 
standard tools available on the battlefield. However, hatches are often secured, 



9 


locked from the inside, or jammed by the incident providing a serious challenge. 
Most hatches of battlefield vehicles can be opened using a size 14 Allen key, 
which can be obtained from any other battle vehicle on scene. If the mechanism 
is however jammed or the specific vehicle is not equipped with this capability, 
force is required. Most recovery vehicles carry a thermal cutting device, which is 
capable of cutting the hinges of the hatch or door. This is, however, a time 
consuming process requiring all applicable fire precautions. Most battle vehicles 
also carry a crowbar on an external mounting that can be used to force the 
hatches open. Emphasis is placed on the use of these tools on the weak points 
such as hatch locks rather than trying to force hinges. 



As soon as access is achieved, airing the vehicle from all harmful gases is a 
critical step. Opening the hatches, however, also provides oxygen to any 
smouldering fires inside the vehicle that may have catastrophic consequences. 
There is no easy solution to these challenges, and often requires simultaneous 



10 


fire fighting with the opening of the hatch. If ordnance explodes at that moment, it 
may kill all rescuers in the close proximity. 

Rescuers must stand back to allow fellow soldiers of the element to deactivate or 
safeguard weapon systems before any rescue interventions. 

As soon as safe access is achieved, sustained patient access must be achieved 
by opening all accessible hatches followed by a secondary size-up to determine 
the number, position and condition of crew members in the vehicle. As medical 
staff are often not orientated to the exact number and position of crew in all battle 
vehicles, using expertise from the army element on scene to identify all 
compartments of the vehicle where a crew member may be trapped is critical. 

A complete check to identify the number of crew members, identify their condition 
through a primary survey, and then to allocate a triage priority will guide the 
disentanglement process. The Triage Sieve Method will be applied in this 
situation. 

DISENTANGLEMENT 

The primary survey is followed by a secondary survey to determine entrapment 
of the casualty. In standard vehicle extrication this entails inline cervical 
immobilisation, basic stabilisation, and then manipulating or removal of all vehicle 
structures that may obstruct extrication. 

The battle vehicle is however a total different scene. First and foremost, the 
battle vehicle, for example, a tank, is a weapon system which is utilised in 
defence of a position or to attack an objective. In this role it is a valuable piece of 
equipment which must be preserved as far as possible and repaired as soon as 
possible. This is specifically applicable to the partially or lightly damaged battle 
vehicle. In the standard vehicle extrication the vehicle is seen as “expendable” 



11 


and is cut away from the casualty. In the battle vehicle the integrity of the vehicle 
is preserved as far as possible to ensure that it can go on fighting as soon as 
possible. Disentanglement in the battlefield scenario is therefore focussed on 
safely manipulating the casualty to remove the casualty from his/her entrapment, 
while preserving the integrity of the battle vehicle as far as possible. 

The construction and interior of the battle vehicle also make it nearly impossible 
to use the standard vehicle extrication disentanglement approach. The 
construction is rigid with heavy steel constructions and extremely limited space. It 
is, for example, impossible to remove any structures around a tank driver due to 
limited space and thickness of the steel structures. 

In-line spinal immobilisation is a standard first step in vehicle extrication. The risk 
for spinal damage is caused by the kinematics of trauma in a vehicle crash. The 
kinematics is directly related to the energy of the crash. The law of conservation 
of energy states that energy cannot be created or destroyed but can be changed 
in form. The implication of this law is that during a vehicle crash the energy of 
motion is dissipated by the bending of the frame and other parts of the vehicle. 
The remaining energy is transferred to the occupants and their internal organs(4). 
It is these forces that result in the blunt trauma in a vehicle crash. In the battle 
vehicle involved in an incident, the minimum energy is absorbed by the frame of 
the battle vehicle as there are very few structures that would bend resulting in 
most of the energy being transferred to the crew inside. If it is taken into account 
that most battle vehicles have very little restrains or safety harnesses for crew, 
this should then result in serious blunt injuries, including possible cervical 
damage. If this argument is followed, in-line spinal immobilisation should be a 
standard immediate action after gaining access to a casualty in a battle vehicle. 
The requirement for spinal immobilisation needs to be analysed in more detail. 



12 


KINEMATICS OF TRAUMA IN BATTLE VEHICLES 


It is not possible to address the total spectrum of physical forces involved in 
battlefield interaction such as kinetic energy, momentum and transfer of energy 
(explosions) within the context of a journal article. To demonstrate the impact, 
only kinetic energy will be analysed. 

Kinetic energy equals one-half the mass times the velocity squared4). If a 
standard sedan vehicle of 1090 kg is travelling at 120 km per hour, the kinetic 
energy involved would therefore be: 

KE of Sedan Car = 1 / 2 im v 2 

=y 2 ( 1090) (432) 2 
=101710080J 
=101710. 08kJ 

If this same calculation is done for an Olifant tank with a mass of 56 000 kg 
travelling at 30km/hour in the veldt, the kinetic energy can be estimated. 

KE of Olifant Tank = 1 / 2 imv 2 

=V2 (56000)(108) 2 

=326592000J 

=326592kJ 


If the kinetic energy is compared Car:Tank 

=101710,08 : 326592 


= 1 : 3.21 



13 


If the principle that the structure of the tank absorbs the minimum of kinetic 
energy during impact is valid, a crew member in a tank is subjected to 3.21 times 
the kinetic energy that is present in a standard sedan vehicle crash. 

The impact of the transfer of energy to the human body resulting in blunt trauma 
is caused by two forces on the body, namely shear and compression^). Shear is 
the result of one organ, structure or part thereof changing speed faster than 
another organ, structure or part thereof. Compression is the result of an organ, 
structure or part thereof being directly squeezed between other organs, 
structures or part thereof. It is these two forces that are of importance when 
analysing the kinematics of trauma to determine the most appropriate and safe 
way to disentangle a casualty from a battle vehicle. 

The analysis of the various effects of kinematics and mechanisms of injury in the 
various battle vehicles falls outside the scope of this paper. To conclude, it must 
be accepted that the forces involved can cause serious shear and compression 
injuries in a crew of any battle vehicle, requiring optimum stabilisation and 
packaging prior to extrication. 

As soon as the weapon system is secured and ordnance declared safe, the 
combat medic should access the vehicle through the access hatches and crawl 
as close as possible to each casualty. Casualties able to free themselves and 
without obvious injuries must be encouraged to extricate themselves from the 
vehicle. Trapped casualties must be assessed to determine what part of the body 
is trapped by what structures. If the crew seat is adjustable, as in the Ratel driver 
position, the seat can be manipulated in an effort to free a casualty. Wearing 
leather protective gloves, palpate each casualty from head to toe to identify 
entrapment. This is not possible for an Olifant tank driver, and difficult for the 
Rooikat driver. In other battle vehicles and other crew positions in a tank and 
Rooikat this is however possible, on condition all hatches are accessible. Where 
possible, limbs are manipulated to free them from entrapment. 



14 


Often driver entrapment is caused by the driver’s boots that become trapped 
among the pedals. By cutting the laces of the boots with a seatbelt cutter, the 
driver’s feet can be freed from the trapped boots. 

Crew members are often trapped by their webbing or uniform (tank overall) which 
can become entangled in an internal structure. Undoing the casualty’s webbing is 
often sufficient to disentangle the crew member; thereby removing casualty from 
his/her entangled webbing. Palpate specifically to determine if uniform 
components are not just hooked onto a structure. 

PACKAGING 

Packaging is at most times executed concurrently with disentanglement. Basic 
principles for packaging are applied. Immobilise where possible prior to 
movement is the basic concept if emergency extrication is not indicated. 

In line cervical immobilisation, as discussed above, should be considered, taking 
the kinematics of the specific incident (mechanism of injury) into account. If the 
battle vehicle was involved in a frontal impact incident, the resulting shear forces 
(flexion and extension) may cause cervical trauma. However, due to the weight 
of the vehicle, a rear or lateral impact has less possibility for shear forces. If 
possible, inline immobilisation and a rigid cervical collar should be considered. 
The use of an extrication device such as a Kendrick is possible in the Ratel and 
Rooikat scenarios and should be used except in emergency extrication actions. 
In the Olifant Tank evolution, however, this is not possible. In extricating the tank 
driver, application of a cervical collar can be attempted, but it is not possible to 
apply any other immobilisation devices. 



15 



Fig 4: Optimally immobilising (packaging) a casualty prior to Extricating. (Note: It 
is seldom possible to apply an extricating device in the confined space of the 
Battle Vehicle and often a rigid cervical collar and manual in-line immobilisation is 

the optimal approach.) 


EXTRICATION 

Extricating is the final step to remove the casualty from the vehicle. In each battle 
vehicle, the most appropriate route for each crew member must be evaluated, 
however, often casualties are thrown from their seats into alternative positions in 
the vehicle by the impact or explosion. Often all the hatches/doors are not 
accessible and alternative egress routes must be used. 

In theory casualties should be extricated in triage priority as the most serious 
need to be removed first to enable medical staff to optimally resuscitate the 
casualty outside the confines of the vehicle. This, however, remains a theoretical 
ideal. Often, access to more serious casualties is obstructed by less injured and 
lightly trapped casualties. In such a situation, the less serious injured casualty 


16 


must be extricated first to enable rescuers to reach the other casualty(s), and to 
provide working space in the confines of the vehicle. 

Due to the nature of battlefield extrication and the serious injuries possible, the 
calling forward of a military paramedic to assist with care and/or a forward 
medical team from the Level 1 Resuscitation Post(5) need to be considered. 

Olifant Tank 

Driver 

The barrel/turret must ideally be moved to the ten past position to allow optimum 
access to the driver’s hatch. No 1 Combat Medic must lie down on his/her 
stomach to the side of the hatch and reach into the driver’s compartment to 
achieve inline immobilisation from the side. No 2 Combat Medic, in a similar 
position from the front, can then apply a cervical collar. 

Standing over the hatch, facing backward, reach down and grip the driver by 
his/her crew handle situated on the back of his/her tank overall, and pull him/her 
vertically upward out of the compartment. As soon as the driver’s torso is lifted 
out of the compartment, the second combat medic, against the turret and facing 
forward, places his/her arms underneath the driver’s armpits and lifts him/her out 
of the compartment supporting him/her against his/her body. Support staff needs 
to position a stretcher on the longitude axes of the tank, holding it at the height of 
the hatch. The driver is then slipped feet first onto the stretcher. 



17 



18 



If the driver’s hatch is inaccessible, the compartment can be accessed from the 
crew compartment by lowering the driver’s chair and dropping the backrest of the 
chair thus providing partial access to the driver. If the driver is unconscious, it is 
nearly impossible to extricate him/her via this escape route. 

Tank commander, gunner and loader 

All tank crew are accessible in the main crew compartment. Although space is 
very limited, it is possible to achieve inline cervical immobilisation and to apply a 
cervical collar. With No 1 Combat Medic supporting the casualty inside and No 2 
positioned over the hatch and pulling the casualty upward by the crew handle of 
his/her tank overall. As soon as the torso is lifted from the hatch, the casualty is 
again supported from under the armpits and lifted from the tank. The easiest is to 
carry the casualty to the back of the tank and to place him/her on a stretcher. 
Heat from the engine can be a hazard. 

An emergency hatch is positioned under the tank and can be opened from the 
outside. Crawling in through this hatch, extrication through this hatch will be a 



19 


basic push and pull action with no possibility of any immobilisation. In the unlikely 
event of a tank overturning, this is the only accessible hatch. 

Rooikat Armoured Car 

Driver 

Turning the barrel to the ten-past position provides optimum space to access the 
driver’s hatch. The driver’s compartment is more spacious than the tank driver’s 
compartment, but it is still challenging to extricate the driver. Inline immobilisation 
and cervical collar application can be achieved from the external position. A 
similar drill to the tank extrication needs to be used. 

Commander, gunner and loader 

The three crew members are accommodated in the main crew compartment. 
Extrication is again upward through the hatches. Placing a stretcher on the grit 
over the engine makes it possible to place the casualty on a stretcher and then to 
lower the stretcher to the ground. The risk that this area may be very hot due to 
the engine needs to be assessed before it is used. 

An emergency side hatch is positioned on the side of the vehicle between wheel 
two and three. This hatch can be used if the main hatches are inaccessible. To 
be able to extricate casualties through this hatch, the turret needs to be in the 
quarter-two position. The Allen key to open the hatch is mounted just above the 
hatch. After opening the hatch, the ammunition box needs to be removed as well 
as the round in the clamps in front of the hatch. Moving the casualty out through 
this hatch is challenging due to various structures that have to be negotiated. 
Moving the turret back to the twelve -o’clock position allows the optimum space 
to move a casualty through this hatch. 




20 



Ratel Infantry Vehicle 

The Ratel is the most spacious of the battle vehicles in use. With a crew of three 
and carrying 9 infantry soldiers travelling at a speed of 80 km/hour it is also the 
vehicle with the biggest risk for extrication. 

Driver 

The driver’s compartment is accessible from the main compartment or through a 
hatch above the driver. It is possible to package the driver using standard 
extrication devices such as the Kendrick. The easiest way to extricate the driver 
is again upwards through the hatch and then sliding the casualty onto a stretcher 
on the “bonnet” section of the Ratel. 

Gunner and Commander 

Extricating these crew members upwards through the hatch is possible, it is, 
however, also possible to extricate them through the side door. If extricated 



21 


through the hatches, the casualty is placed on a stretcher on top of the vehicle 
and then lowered to the ground. 

Infantry Crew 

These members can be extricated without much trouble through the side doors, 
rear door or any of the roof hatches. Immobilisation is possible prior to extrication. 
It must be emphasised that, as no safety harnesses are used, head and neck 
injuries are serious possibilities. 

G6 Gun 

One of the most challenging vehicles to extricate casualties from is the G6 gun 
due to the height of the crew compartment door and the depth inside the crew 
compartment. 

The only door to the crew compartment is very narrow and positioned to the side 
of the compartment. Casualties can be stabilised and immobilised using 
extrication devices in the crew compartment, but they need to be man-handled 
through the door. Adequate space is available on the landing outside the door to 
position a spine board. The casualty can therefore be slid out of the crew 
compartment onto a spine board. 

Due to the height of this section of the vehicle it is impossible to safely lower the 
spine board from this position to the ground. The most appropriate method is to 
back an Mfezi ambulance against the G6-gun and then to slide the spine board 
over to the top stretcher of the Mfezi. 



22 



Fig 7: Transferring a Stretcher Casualty from the G-6 Gun to the Mfezi 

Ambulance 


POSITIONING CASUALTIES AFTER EXTRICATION 

It is a standard Army drill to position all casualties next to the left front 
wheel/track of the vehicle. This is not practical for the G6 gun due to the drill to 
move the casualty directly into the ambulance. 

Taking enemy positions into account, this drill can be applied and stabilisation 
then carried out prior to evacuation. 




23 



Fig 8: Military Paramedic Establishing a Stabilisation Point at the Left Front of a 

Battle Vehicle 


EMERGENCY EXTRICATION 


The unique battlefield situation, enemy action or risks of exploding ordnance may 
require the emergency extrication of casualties from a vehicle. If the commander 
identifies a risk, he/she may order an emergency extrication. In this drill every 
casualty that is not trapped is dragged out at best speed. In the Armour vehicles 
this will entail using the crew handle on the tank overall and dragging the 
casualty out by force. If time and situation permit, an effort can be made to free 
partially trap casualties and drag them to safety. Trapped casualties will however 
have to be sacrificed or left to the enemy in an emergency situation. 

Taking the weight and construction of battle vehicles into account, the risk exists 
that a trapped casualty could not be freed from his/her entrapment and that an 


24 


emergency amputation may be required. If this scenario occurs, the damage 
control surgery team from the Level 1 Medical Post must be sent forward to 
execute the amputation. This requires basic anaesthesia skills and basic surgical 
capabilities. In ideal situations, the Orthopaedic surgeon from the Level 2 Field 
Hospital should be requested to execute the amputation(5). 

THE ROLL-OVER BATTLE VEHICLE EVOLUTION 

Although heavy track vehicles such as tanks are very stable platforms, the risk 
does exist that such a vehicle may slide down an embankment, fall into a tank- 
trap or roll-over due to a steep incline. If the limited vision of the tank-driver 
through his scopes is taken into account, this scenario is a real possibility. Many 
extrication experts have debated this scenario at various forums. If the size and 
position of the emergency hatch underneath the tank is taken into account, a 
near impossible extrication scenario exists. It has happened in history that the 
only solution was to upright the tank with the crew inside, open the hatches and 
then to try and do what is possible for the surviving crew. 


PATIENT TRANSPORTATION 

Taking the battlefield situation into account, all casualties are assembled at the 
front left corner of the vehicle. A stabilisation point is established at this position 
and casualties re-triaged and stabilised. If this position is exposed to enemy fire, 
an alternative, more secure position must be identified. Preferably, the Sort 
method of triage should now be utilised to determine evacuation priorities. Taking 
the compression forces of the mechanism of injury into account, internal bleeding, 
especially thoracic and abdominal, need to be a major concern, as these non- 
compressible bleeding will require damage control surgery, time must not be 



25 


wasted at the stabilisation point prior to evacuation. The danger of starting re- 
bleeding if the blood pressure is dramatically improved through intravenous fluid 
infusion needs to be considered, with the guideline to maintain a palpable radial 
pulse. 

If a casualty is trapped under an armoured vehicle, the risk of traumatic asphyxia 
exists. In lifting the vehicle this risk should be considered with oxygen 
administration and judicious ventilation support provided4). 

CONCLUSION 

Battlefield extrication is a complex and ill described activity. The kinetic energy 
created by battle vehicles hold the risk for serious shear and compression forces 
to cause serious injuries. However, standard extrication processes cannot be 
directly applied in battle. This requires using the standard steps of an extrication 
evolution but adapting it for the circumstances. Extrication tools are limited to the 
standard recovery vehicle and the tools on the battle vehicle, while the paradigm 
is for optimal conservation of the partially damaged battle vehicle. Armoured 
steel, weight, space, unexploded ordnance and weapon systems all jeopardise 
the actions. Stabilising the battle vehicle requires innovative thinking and 
optimum use of available resources. 

Different battle vehicles require unique evolutions to gain access, disentangle, 
package and extricate casualties from the various positions in the vehicle. 

As the Military Health Service, according to its doctrine and philosophy, accepts 
responsibility for care from point of injury, the role of the combat medic to 
extricate casualties cannot be negated. In this role he or she is, however, heavily 
dependent on the technical recovery staff’s and the fighting elements’ expertise 
to extricate casualties successfully. The combat medic however remains 



26 


responsible to guide the extrication process from a functional (medical) 
perspective, and to ensure that optimum care is provided. 

Within the battlefield situation, the risk for emergency situations necessitating 
emergency scoop and run operations always exist and the frightening possibility 
of having to sacrifice a trapped casualty during enemy action or a threatening 
explosion. 

The ability to extricate casualties in battle vehicles is based on good basic 
knowledge of the science of extrication and proper training to apply and 
improvise those skills in battlefield conditions. 

ACKNOWLEDGMENT 

The authors would like to acknowledge the staff of ISA Tank Regiment, 1 
Special Service Battalion and 4 Artillery Regiment for their assistance. A 
special word of appreciation to Tpr D.N. Rowe, Tpr R.G. Ambrose and Tpr 
J.W. Dippenaar for their contribution and help. Their willingness to 
demonstrate and take part in numerous exercises in the heat of Lohathla 
is acknowledged. 


REFERENCES 

(1) International Fire Service Training Association. Principles of Vehicle Extrication. 2nd 
ed. Smith C, editor. Stilwater: Fire Protection Publications; 2000. 

(2) Moore RE. Vehicle Rescue and Extrication. 2nd ed. St Louis: Mosby Jems; 2003. 

(3) Baccino-Astrada A. Manual on rights and duties of medical personnel in Armed 
Conflicts. 2006. 

(4) Prehospital Trauma Life Support Committee. PHTLS Prehospital Trauma Life 
Support Military Edition McSwain N, editor. St Louis: Mosby Elsevier; 2007. 

(5) South African Military Health Service. Operational Doctrine Pretoria: SAHMS; 2008. 



Health Care Management of Radiation 
Casualties 


Col B.P. Steyn 

MBChB (UP), M Med (Anaes)(UP) 

Chemical and Biological Defence Advisor to the Surgeon General 


ABSTRACT 


All humans are exposed to certain levels of naturally occurring radiation 
without any harm. Ionizing radiation is radiation that causes ionisation 
of atoms and is potentially harmful to humans. 

The effects of ionising radiation on humans are the result of changes to 
the DNA and other sub-cellular structures with resultant cellular damage 
that may be repairable or may result in cellular death. Radiation effects 
are determined by dose rates, time of exposure and distance from the 
source of radiation. 

High dose rates may lead to Acute Radiation syndrome, which consists 
of four elements, namely haematopoietic syndrome with depression of 
blood forming organs, gastrointestinal syndrome affecting the 
gastrointestinal system, neurovascular syndrome affecting the brain 
and muscles, and cutaneous syndrome affecting the skin. 

Treatment of radiation patients is primarily supportive by some 
additional specialised procedures such as stem cell transplantation 
when required. 

The health care management of patients exposed to radiation is 
complex and demands a well coordinated multidisciplinary effort. 
Therefore, it is necessary that health care personnel have some 
knowledge of the effects and management of radiation injury. 

The fact that the effects of radiation occur after a time period indicates 
that the primary responsibility of emergency workers at the incident is 
to determine the presence and levels of radiation through well 



2 


documented information and monitoring, while treatment will primarily 
occur at hospital level. 


INTRODUCTION 

All living creatures are exposed to certain levels of radiation (background 
radiation) that occurs naturally due to trace amounts of radioactive materials 
that occur everywhere; in the soil, building materials, food and drink, the air, 
our own bodies (muscles, bones, and tissue) and sea water. The earth is also 
subject to radiation from outer space called cosmic radiation. Background 
radiation must always be taken into account when radioactivity is measured. 

Humanly produced radiation, such as X-rays, radiation for diagnostic 
procedures and cancer therapy, and small quantities of radioactive materials 
released into the environment from coal and nuclear power plants are also 
sources of radiation. 

TERMINOLOGY 

In order to have a clear understanding of all the aspects related to radiation, it 
is necessary that some concepts are described. 

Atomic Structure 

The atom is the basic unit of all matter. It consists of a nucleus around which 
one or more electrons circle. The nucleus consists of protons and neutrons. 
Electrons are negatively charged, protons are positive and neutrons have no 
charge. In most atoms there are an equal number of electrons and protons 
and, therefore they have no electrical charge (1 ,2). 

Atoms combine to form molecules which are the building blocks of matter. 



3 


Ionisation 

An ion is an atom that has an electrical charge due to an imbalance between 
the numbers of protons and electrons. 

Ionisation is the process in which an atom or molecule is converted to an ion 
by adding or removing electrically charged particles (electrons or protons) 
from the atom or molecule (1 , 2). 

Radioactivity 

Some natural elements are unstable; their nuclei tend to disintegrate with 
resultant release of energy in the form of radiation. This phenomenon is called 
radioactivity. Radioactive atoms are called radionuclides (1, 2). 

Ionizing Radiation 

The radioactive emissions listed above will increase the ability of any medium 
through which they pass to conduct an electrical current, in other words, they 
will ionise that medium. Therefore, the radiation caused by these emissions is 
called ionizing radiation (1). 

In living tissue ionizing radiation causes damage to organic molecules and 
therefore, to living cells and tissues. In this regard DNA is of particular 
importance. 

Non-Ionizing Radiation 

Non-ionizing radiation does not have the amount of energy needed to ionize 
an atom with which it interacts. 

Sources of non-ionizing radiation include sunlight, microwaves and infrared 
lights. 


Radiation types 

There are four known types of ionizing radiation: 


a. Alpha Radiation . Alpha radiation is produced by alpha particles. 
Alpha particles are heavy, positively charged particles emitted by 



4 


large atoms of elements such as uranium and radium. They can 
only travel a short distance (2,5 - 4 cm) in the atmosphere and can 
be stopped completely by a sheet of paper or by the epidermis. 
However, if alpha-emitting materials are taken into the body, they 
will cause serious biological damage to living cells (1 , 2). 

b. Beta Radiation . Beta particles cause Beta radiation. Beta 
particlesare high-speed electrons. They can travel up to 3m through 
the air and are more penetrating than alpha particles. They can 
pass through up to around 1 cm of water, but are shielded by plastic 
safety glasses and thin metal sheeting such as aluminium. Beta 
particles pose an external and internal hazard to humans (1 ,2). 

c. Gamma Ravs . Gamma rays are not material particles, but energetic 
photons of invisible light. Depending on their energy, they can pass 
right through the human body, but can be stopped by thick walls of 
concrete or lead. Gamma rays pose external as well as internal 
hazards (1 ,2). 

d. Neutrons . Neutrons are uncharged particles and do not produce 
ionisation directly, but their interaction with the atoms of matter can 
give rise to alpha, beta, gamma, or X-rays that then produce 
ionisation 2 . Neutrons have a long range, are relatively penetrating in 
tissue, but are shielded by hydrogenous materials such as water 
and paraffin. 

EXPOSURE TO IONISING RADIATION 

The factors influencing the effects of ionizing radiation are the dose of 
radiation the tissue receives, the duration of exposure as well as the distance 
from the source of radiation. 

Exposure can be acute, prolonged or intermittent. It can occur alone or in 
combination with other injury. 



5 


Radiation Dose 

The radiation dose that allows for different relative biological effects of the 
different types of radiation is called the equivalent dose and is measured in 
Sieved (Sv). Radiation doses are normally expressed in millisievert (mSv) or 
microsievert. The average radiation exposure due to natural background 
sources amounts to approximately 2.4 mSv a year. 

Lower doses will only have effects after prolonged exposure, while acute 
effects may develop after short exposure to very high doses. Since long term 
exposure is more relevant for lower doses, such doses are usually defined in 
terms of exposure over time and are expressed in mSv/hour or mSv/annum. 


RADIATION DOSE 

BIOLOGICAL EFFECTS 

2,4 mSv/a (approximately) 

Normal background radiation. 

< 100 mSv 

No effects. 

1 00 - 250 mSv 

Minor blood effects possible after acute 
exposure. 

1000 mSv 

Exposure over time to reach this dose may 
cause cancer in the long-term. 

3 000 mSv 

Gastro-intestinal effects such as nausea and 
vomiting as well as decreased white cell 
count. Patients usually recover. 

3 000 - 10 000 mSv 

Severe radiation sickness. 50% mortality after 
30 days. 

>10 000 mSv 

Death within a few weeks. 


Table 1 : The dose effects of ionising radiation (2, 3) 


Duration of Exposure 

A person has to be exposed to radiation for a certain period of time for 
negative effects to occur. The higher the dose the shorter the time period one 
can remain without effect under that specific dose rate. 




6 


There are guidelines and time indicators available that indicate safe time 
periods under specific radiation doses, so-called stay times. These tables are 
used as indicators during rescue operations due to the fact that there is not 
sufficiently complete protection against gamma radiation available. The stay 
time can be calculated as follows: 

Stay time = Exposure limit/dose rate 


Radiation Dose 

Stay time to receive dose 


10 mSv 

100 mSv 

1 Sv 

0,01 mSv/h 

6 weeks 

1 year 

- 

1 mSv/h 

10 hours 

100 hours 

6 weeks 

1 0 mSv/h 

1 hour 

10 hours 

100 hours 

1 00 mSv/h 

6 minutes 

1 hour 

10 hours 

1 Sv 

36 seconds 

6 minutes 

1 hour 


Table 2: Examples of stay times (4) 


Distance from Source 

The radiation dose rate decreases with distance from the source of radiation 
according to the inverse square law. The dose rate at a source will decrease 
to Vi of the original dose rate when distance is doubled and to 1/9 when the 
distance is trebled. Therefore, distance from the source of radiation plays an 
important role as a protection measure against radiation injury. 

Routes of Entry 

Radiation or radioactive materials can enter the body through inhalation, 
ingestion, absorption through the skin and through open wounds. Radiation 
will also affect the skin directly and, in many instances, the skin will show the 
first signs of radiation injury. 

Types of Exposure 

People can be exposed to radiation from sources external to the body, which 
may be to the body as a whole or only to parts of the body, or to internal 
sources due to inhalation, ingestion or absorption through open wounds after 
contamination with radioactive materials. 




7 


A patient with internal exposure or external exposure that is not related to 
contamination is not a source of radiation and does not pose a danger to 
health care personnel. However, patients that have been contaminated may 
pose a risk to others and need to be decontaminated. 

BIOLOGICAL EFFECTS OF RADIATION 

Ionising radiation affects atoms through ionisation. Therefore, biological 
effects are the result of ionisation of atoms in cellular structures. For low 
levels of radiation exposure over short time periods, the biological effects are 
so small that they may not be detected because the body has repair 
mechanisms against damage caused by radiation. 

The effects of radiation can be direct or indirect. 

Direct effects occur through direct interaction with the atoms of the DNA 
molecule or some or critical cellular elements with resultant cellular 
malfunction or death. The probability of this mechanism occurring is small due 
to the fact that the DNA molecules make up such a small part of the cellular 
structure. 

The indirect effects due to interaction between the radiation and the cellular 
water are more probable. The radiation releases energy in the water which 
leads to the creation of unstable toxic, hyperoxide molecules such as 
Hydrogen Peroxide (H 2 O 2 ). These molecules interact with others breaking 
chemical bonds and producing new chemical bonds and cross-linkage 
between macromolecules damaging molecules that regulate vital cell 
processes causing damage to sub-cellular structures. The cell can repair 
certain levels of cell damage caused by low doses of radiation, but at higher 
doses cell death will result from exposure. Damaged cells may still reproduce, 
but the daughter cells may be lacking in some critical components and they 
die or they mutate and reproduce. Such reproduction of mutated cells may 
become malignant tumours (5, 6, 7). 

Actively producing cells are more sensitive to radiation than those that 
reproduce less actively. The blood forming cells (particularly Lymphocytes) 
are the most sensitive reproductive organs and gastrointestinal cells are less 



8 


sensitive followed by skin, while bone, teeth, muscle and nerve cells are the 
least sensitive. 

The biological effects of radiation are divided into: 

a. Acute Effects . Acute effects occur after exposure to high doses of 

radiation over a short period of time (minutes to hours). These 
effects tend to kill cells and damage tissue and organs if the dose is 
sufficiently high. 

b. Chronic Effects . Chronic effects occur after long term exposure to 

low doses of radiation. The effects of low doses are on cellular level 
and, therefore, they do not cause immediate damage to tissue or 
organs. The effects may only become visible after many years (5 - 
20 years). Since chronic effects of radiation fall outside the scope of 
this article, it will not be discussed in more detail. 


Acute effects 

High radiation doses can kill so many cells that tissue and organs are 
damaged immediately resulting in a whole body response called Acute 
Radiation syndrome. Approximately 134 plant workers and fire-fighters 
battling the fire at the Chernobyl power plant received high radiation doses 
(800 to 16,000 mSv) and suffered from acute radiation sickness. Of these, 28 
died within the first three months from their radiation injuries (8). 

The extent of the pathological effects of radiation vary from person to person 
and is dependent on factors such as the general health status of the individual 
before exposure and the medical care received after the exposure. However, 
it is estimated that 50% of a population exposed to 3 500 mSv - 5 000 mSv 
over a period ranging from a few minutes to a few hours would die within thirty 
days after receiving a dose to the whole body (LD50/30) (8). 

Similar exposure of only parts of the body will likely lead to more localized 
effects, such as skin burns. 



9 


Acute Radiation Syndrome (ARS) 

ARS occurs after exposure of the whole body or large parts of the body to a 
high radiation dose (>1 000 mSv) over a relatively short time period. 

ARS consist of one or more of the following clinical syndromes: 
haematopoietic syndrome with depression of blood forming organs; 
gastrointestinal syndrome affecting the gastrointestinal system; neurovascular 
syndrome affecting the brain and muscles; and cutaneous syndrome affecting 
the skin. 

Each syndrome consists of a prodromal phase, latent phase, manifest illness 
and recovery or death depending on the exposure dose rate. 

The typical course of ARS involves an initial prodromal phase with non- 
specific symptoms such as nausea, vomiting, fatigue, malaise and loss of 
appetite. An early onset of symptoms in the absence of associated trauma 
suggests exposure to a large radiation dose (6). 

The prodromal phase is followed by a latent phase in which the patient is 
relatively symptom free. The length of this phase varies with dose. The latent 
phase is the longest preceding the hematopoietic syndrome and may vary 
between 2 and 6 weeks. It is somewhat shorter prior to the gastrointestinal 
syndrome, duration of a few days to a week. It is the shortest of all preceding 
the neurovascular syndrome, lasting only a matter of hours. These times are 
variable and may be influenced by the presence of other disease or injury. 
Therefore, it is not practical to hospitalize all personnel suspected of having 
radiation injury early in the latent phase. 

Clinical illness follows the latent phase. It is characterised by the clinical 
symptoms associated with the injured organ systems including anaemia, 
infection, bleeding, gastrointestinal symptoms and neurovascular symptoms. 


Haematopoietic Syndrome 


10 


The primary element of this syndrome is bone marrow depression that leads 
to pansitopaenia. The first peripheral blood changes will become apparent 
within 24 hours after exposure. Lymphocytes will be depressed first, followed 
by other leukocytes and thrombocytes. The average time for the onset of 
bleeding, anaemia and decreased resistance to infection is 2 to 3 weeks and 
potentially lethal cases of bone marrow depression may occur 6 weeks after 
exposure. The most useful laboratory procedure to evaluate marrow 
depression is the peripheral blood count. A50% drop in lymphocytes within 24 
hours indicates significant radiation injury. Early therapy should prevent nearly 
all deaths from marrow injury alone (6). 

Gastrointestinal Syndrome 

Radiation causes loss of intestinal crypts and breakdown of the mucosal 
barrier resulting in abdominal pain, diarrhoea, nausea and vomiting, and 
predisposes patients to infection. The gastrointestinal syndrome will almost 
always be accompanied by bone marrow suppression. The prodromal phase 
is characterised by nausea, vomiting, watery diarrhoea and cramps. 
Symptoms subside during the latent period. Manifest illness consists of 
vomiting, severe diarrhoea associated with high fever and systemic effects 
which may include malnutrition from malabsorption; bowel obstruction from 
ileus; dehydration, cardiovascular collapse, and electrolyte derangements 
from fluid shifts; anaemia from damage to the intestinal mucosa and 
microcirculation, and subsequent gastrointestinal bleeding; and sepsis and 
acute renal failure. Treatment consists primarily of fluid replacement and 
prevention of infection. (6, 9). 

Neurovascular Syndrome 

The neurovascular syndrome is associated only with very high acute doses of 
radiation (20-40 Sv) and its stages are compressed. The prodromal phase is 
characterised by disorientation, confusion, and prostration and may be 
accompanied by loss of balance and seizures. Physical examination may 
show papill-oedema, ataxia, and reduced or absent deep tendon and corneal 
reflexes. During the latent period, apparent improvement occurs for a few 
hours and is followed by severe manifest illness. Within 5 to 6 hours, watery 


11 


diarrhoea, respiratory distress, hyperpyrexia, and cardiovascular shock can 
occur with a steady deteriorating state of consciousness and eventual coma 
and death (6, 9). 

Cutaneous Syndrome 

Cutaneous injury usually occurs after partial body or local exposure 
depending on the dose. The epidermis, dermis and at times deep soft tissue 
and even underlying muscle may be affected in cases of exposure to high 
doses. Symptoms include erythema, pain, oedema, dry and wet 
desquamation, blistering, necrosis and gangrene. Oedema, which places the 
patient at risk for a compartment syndrome, may develop. Local skin injuries 
develop over weeks to months and are difficult to treat with standard 
methods(9, 8) 

MEDICAL MANAGEMENT 

The medical management of radiation and combined injuries can be divided 
into three stages: triage, emergency care, and definitive care. During triage, 
patients are prioritized and rendered immediate lifesaving care. Emergency 
care includes therapeutics and diagnostics necessary during the first 12 to 24 
hours. Definitive care is rendered when final disposition and therapeutic 
regimens are established. 

The most important aspect of emergency radiation exposure management is 
the recognition of such an incident and the determination of levels of 
exposure, type of exposure and the need for decontamination. 

Actions when radiation injury is suspected 

a. In individual cases, it is important to obtain as complete a history 
from the patient as possible. Information such as contact with 
any unknown or metallic object, similar symptoms amongst 
family members and knowledge about the mechanism of injury 
should be obtained. 



12 


b. If contamination is suspected, the patient must first be 

decontaminated, all other cases pose no threat and 
management should continue normally. 

c. A full blood count should be done as soon as possible and should 

be repeated every 4-6 hours. A drop in absolute lymphocyte 
count will indicate recent exposure. Low total white cell and 
platelet counts will indicate exposure a few days to weeks 
earlier. 

d. Although symptoms develop over time, the primary goal should 

be the evacuation of a radiation casualty prior to the onset of 
manifest illness. 

Triage 

Associated conventional injuries must always be treated first because 
radiation does not produce early life threatening symptoms. Therefore, the 
primary purpose of triage on the scene of injury is to sort patients according to 
conventional injuries or other non-radiation-related conditions. 

The purpose of radiation-related triage is to: 

a. Identify those that have been exposed to radiation; 

b. Identify those that have not been exposed; and 

c. Determine whether those exposed to radiation have been 
contaminated in order to decontaminate them. 

The primary activities required for triage at this stage are proper history 
taking and monitoring for radiation. Patients with conventional injuries must 
be monitored and interviewed first to determine radiation status. 

The next level of triage will be at hospital where the purpose is to: 

a. Identify those who have been exposed to radiation and will 
definitely require further treatment; 

b. Identify those who may have been exposed to low levels of 
radiation that might have an effect on their health. Those will 
mostly be long term effects; and 

c. Identify those that might have been exposed, but the exposure 
would not have an effect on their health (10). 



13 


History, monitoring and full blood count are essential tools at this level as well 
as the presence of early symptoms of ARS. A full blood count should be done 
on all those exposed with follow-up tests as described previously. People in 
the third category must be followed up for a period to ensure that they have 
not been affected. 

Definitive Treatment 

Supportive treatment and management of symptoms are the most important 
elements of treatment of these patients. Supportive treatment includes the 
administration of antibiotics, antiemetic agents, anti-diarrhoeal agents, fluids, 
electrolytes, analgesic agents and topical burn creams. 

Prevention of Infection 

Prophylactic antibiotic therapy should be directed against gram-negative 
bacilli. In patients who do not have neutropenia therapy should be directed 
against specific infections while those with neutropenia should be treated with 
broad spectrum antibiotics (9, 10). 

Nutrition should include an enteral hypercaloric diet, glutamine and sucralfate 
to protect the enteral mucosa, parenteral nutrition and fluid and electrolyte 
replacement as required(IO). 

Dermoprotector creams in the prodromal phase, topical or systemic steroids, 
hydrocolloid dressings, local infection prophylaxis and treatment should be 
considered for skin treatment (10). 

Specialised treatment such as cytokine therapy, blood transfusions and stem 
cell transplantation should be considered and implemented according to 
necessity in a specialist environment (9). 

CONCLUSIONS 

Radiation accidents are rare, however, the number of accidents and incidents 
have increased internationally. The health care management of patients 
exposed to radiation is complex and demands a well coordinated 


14 


multidisciplinary effort. Therefore, it is necessary that health care personnel 
have some knowledge of the effects and management of radiation injury. 

The fact that the effects of radiation occur after a time period indicates that 
the primary responsibility of emergency workers at the incident is to 
determine through well documented information and monitoring the presence 
and levels of radiation, while treatment will primarily occur at hospital level. 

REFERENCES 

(1) Edwards G. Health and Environmental Issues linked to the Nuclear Fuel Chain. Prepared 
under contract to the Canadian Environmental Advisory Council. 

(2) lnstitute for Water Quality Studies. Radioactivity Calculation and Water Quality Evaluation 
Guideline for Domestic Water Use. March 2002 

(3) Lecture notes US State Department Emergency Response Training Programme. 2001 

(4) US Dept of Energy Transport Emergency Programme: Transport Emergency 
Preparedness Programme, Emergency Responder Radioactive Material Quick Reference 
Sheet. 

(5) IAEA & WHO Pamphlet: How to recognise and initially respond to an accidental radiation 
injury 

(6) Jarrid D. Medical Management of Radiological Casualties. 1 st Edition, 1999. Military Medical 
Operations Office Armed Forces Radiobiology Research Institute, Bethesda, Maryland20889- 
5603. 

(7) Open Source Radiation Safety TrainingModule 3. Biological Effects. PrincetonUniversity 

(8) U.S. Nuclear Regulatory Commission; Fact Sheet on Biological Effects of Radiation. 

(9) Waselenko JK, MacVittie T, Blakely F, et al. Medical Management of the Acute Radiation 
Syndrome: Recommendations of the Strategic National Stockpile Radiation Working Group. 
Annals of Internal Medicine. 2004; 12: 1037-51. 

(10) Rojas-Palma C., Liland A., Jerstad A., et al. Triage, Monitoring and Treatment of People 
Exposed to Ionising Radiation Following a Malevolent Act.Norway NRPA. 2009. 70-318 

(1 1) Biological Effects of Radiation, USNRC Technical Training Centre 

(12) Bertell R. No Immediate Danger, Prognosis for a Radioactive Earth. Summertown, 
Tennessee, The Book Publishing Company. 15-63 



Continuous Professional Development 
Questionnaire 1 


INSTRUCTIONS 

• All health care professionals are required to collect a prescribed number of CPD 
points annually to register with the Statutory Council. Although this requirement 
is not yet formalised for the nursing professions, it is advised that the 
questionnaire be completed. 

• Study all the articles in the journal. Complete the questionnaire at the back of the 
journal and return it to: 

School for Military Health Training 
Private Bag X 1 022 
Thaba Tshwane 
0143 

• Three (3) CPD points will be awarded to candidates who obtain more than 80% 
in the open book completion of the questionnaire. 

Basic Mechanical Ventilation in the Operational Theatre 

1 . The three (3) basic variables necessary to ventilate a patient are: 

i. Oxygen 

ii. C0 2 

iii. Frequency 

iv. Volume 

v. Humidification 

A i, ii, iii 

B ii, iv, v 

C i, ii, v 

D i, iii, iv 



E i, ii, iv 

2. In order to mechanically ventilate an 85 kg patient on the battlefield, a tidal 

volume (Vj) setting of will be set. 

A 85 ml 

B 850 ml 

C 8.5 1 

D 680 ml 

E 6.8 1 

3. In order to effectively increase the alveolar ventilation, will be 

increased. 

A Frequency 

B Tidal Volume (V T ) 

C Oxygen percentage 

D C0 2 

E Humidification 

4. In order to prevent barotrauma to a mechanically ventilated patient in austere 
conditions, the peak inspiratory pressure (PIP) maximum setting on the ventilator should 
not exceed: 

A 15cmH 2 0 

B 30 cmH 2 0 

C 40 cmH 2 0 

D 50 cmH 2 0 

E 60 cmH 2 0 



5. A possible side effect of initiating positive end expiratory pressure (PEEP) for 
mechanically ventilated patients on the battlefield is: 

A Increased haemoglobin saturation 

B Decreased incidence in pneumothorax 

C Decreased intra cranial pressure (ICP) 

D Decreased venous return 

E Increased peripheral cyanosis 

Health Care Management of Radiation Casualties 

6. The effects of ionising radiation can be influenced by: 

i. Dose received 

ii. Distance from source 

iii. Duration of exposure 

iv. Personal exercise habits 

v. Regular use of antibiotics 

A i, ii, iii 

B i, ii, v 

C Only i 

D Only iii 

E All of the above 

7. Which of the following tests could be deemed most useful to evaluate bone 
marrow depression during Acute Radiation Syndrome (ARS)? 

A Liver function test (LFT) 

B Full blood count (FBC) 

C Peripheral blood smear 

D Bone Marrow biopsy 



E Long bone X-rays 


8. Decontamination of radiological contaminated patients takes preference to 
ensuring an adequate airway. 

A True 

B False 

Airway Management in the Military Environment 

9. In order to clear a casualty’s airway from visible foreign bodies on the battlefield, 
the airway can be swept with a gloved finger. 

A True 

B False 

1 0. A casualty with a suspected cervical spine injury should be turned on his side 
while maintaining inline cervical stabilisation in order to clear the airway when he starts 
to vomit. 

A True 

B False 

1 1 . Which of the following is NOT considered a reason for ineffective bag-valve- 
mask ventilation? 

A Poor mask seal 

B Foreign body in the airway 

C Ineffective jaw thrust manoeuvre 

D Obstruction by another upper airway adjunct 
E Oxygen concentration less than 1 00% 



1 2. A nasopharyngeal airway can be used in a patient with a gag reflex. 

A True 

B False 

1 3. The only safe airway that will prevent aspiration is a 

A Cuffed endotracheal tube 

B Oropharyngeal tube 

C Laryngeal mask airway (LMA) 

D Partial rebreather mask 

E Nasopharyngeal airway of the correct size 

14. While providing care under direct fire, airway management takes preference to all 
other aspects. 

A True 

B False 

Haemostatic Technologies to Control Bleeding on the Battlefield 

1 5. An incorrectly applied tourniquet can cause more bleeding. 

A True 

B False 

1 6. Which of the following is NOT recommended during the use of a tourniquet? 

A Cover the tourniquet after application 

B Record the use of a tourniquet in an obvious place 
C Remove the tourniquet at the first appropriate opportunity 



D Use a wide tourniquet 

E Ensure that other medical personnel along the line of evacuation know that a 
tourniquet has been applied. 

1 7. Which of the following is NOT considered a basic activity to control bleeding by 
every soldier before applying a tourniquet? 

A Direct pressure 

B Application of a dressing 

C Establishing an intravenous line 

D Elevation of a limb 

E Pressure on a pressure point 

Vehicle Extrication on the Battlefield 

1 8. The basic sequence of vehicle extrication on the battlefield (not under direct fire) 
is: 

A Scene size-up; Patient access; Disentanglement; Packaging; Extrication 

B Scene size-up; Patient access; Disentanglement; Extrication; Packaging 

C Patient access; Scene size-up: Disentanglement; Extrication; Packaging 

D Disentanglement; Extrication; Packaging; Patient Access; Scene size-up 

E Scene size-up; Patient access; Extrication; Disentanglement; Packaging 

1 9. After all-round defence is in place, the battle vehicle’s own weapons are deemed 
the immediate threat to the rescuers’ safety. 

A True 

B False 



20. If an emergency extrication is not indicated, immobilisation prior to movement is 
considered the basic concept. 


A True 

B False 



Continuous Professional Development 
Questionnaire 2 
Triage 


INSTRUCTIONS 

• All health care professionals are required to collect a prescribed number of CPD 
points annually to register with the Statutory Council. Although this requirement 
is not yet formalised for the nursing professions, it is advised that the 
questionnaire be completed. 

• Study all the articles in the journal. Complete the questionnaire at the back of the 
journal and return it to: 

School for Military Health Training 
Private Bag X 1 022 
Thaba Tshwane 
0143 

• Three (3) CPD points will be awarded to candidates who obtain more than 80% 
in the open book completion of the questionnaire. 


Triage each of the following patients according to Triage SIEVE and Triage SORT 



• Fluid Requirement: 1 Litre 

• Blood Requirement: 0 Units 

• Blood Group: A Pos 

• Theatre Time: 0 Hours 30 Min Level 2 


Patie nt No: 1 


History: A soldier with a shrapnel wound to 
left temporal. 

Mobility: Was walking requested to lie down 
Airway: Open 
Skin: Pale 

Breathing Quality: Normal 

Breathing Rate: 18/min 

Pulse Quality: Normal 

Pulse Rate: 124/min 

Blood Pressure: 120/80 mmHG 

Findings: Shrapnel wound to the head. Not 

penetrated the skull. 

Neurological Status: Orientated; complains 
of a serious headache; feels pain; obeys 
commands; opens eyes spontaneously; 
pupils equal and reacting to light. 


Patient No: 2 



Picture: www -.mother jones. com 


History: A 21 -year-old soldier that was 
involved in a mortar explosion. 

Mobility: Sitting 

Airway: Open, but spitting out blood 

Skin: Pale, cool and moist 

Breathing Quality: Normal 

Breathing Rate: 32/min 

Pulse Quality: Normal 

Pulse Rate: 1 15/m in 

Blood Pressure: 115/75 mmHG 

Findings: Multiple small shrapnel wounds to 

face: forehead, left eye, upper lip and cheek. 

Bleeding from left ear. 

Neurological Status: Seems orientated; but 
does not respond to verbal stimuli or any 
questions; feels pain; pupils equal and 
reacting normally; says in a monotonous 
voice that he cannot hear. 


• Fluid Requirement: 2 Litre 

• Blood Requirement: 0 Units 

• Blood Group: O Pos 

• Theatre Time: 1 Hours 0 Min 

• Require: CT Scan/ Head x-ray 


Patient No: 3 



History: A 19-year-old soldier that was 

involved in a hand grenade explosion. 

Mobility: Walking 

Airway: Open 

Skin: Pale and warm 

Breathing Quality: Regular 

Breathing Rate: 22/min 

Pulse Quality: Normal 

Pulse Rate: 136/min 

Blood Pressure: 120/80 mmHG 

Findings: Small shrapnel wounds over face. 

Dark glasses dotted with marks. 

Neurological Status: Orientated; talking; 

feels pain; obeys commands; pupils equal 

and reacting to light; indicated that he lost 

consciousness for about 5 min after the 

incident. 


• Fluid Requirement: 0 Litre 

• Blood Requirement: 0 Units 

• Blood Group: O Pos 

• Theatre Time: 0 Hours 0 Min 


Patient No: 4 



Picture.-www:al-ghoul. com 


History: A 19-year-old soldier involved in an 

explosion of an unknown explosive device. 

Mobility: Lying 

Airway: Open 

Skin: Warm and pale 

Breathing Quality: Shallow and fast 

Breathing Rate: 34/min 

Pulse Quality: Shallow and fast 

Pulse Rate: 1 16/min 

Blood Pressure: 1 10/70 mmHG 

Findings: Complains of shortness of breath. 

Right side of chest dull on percussion. Trachea 

central no neck vein distension. 

Neurological Status: Orientated; opens eyes 
spontaneously; obeys commands; pupils equal 
and reacting to light. 

Medic established 1 x Peripheral line right arm. 


• Fluid Requirement: 2 Litre 

• Blood Requirement: 2 Units 

• Blood Group: O Pos 

• Theatre Time: 0 Hours 30 Min 

• X-Ray: Massive Right Heamo Thorax 




Patient No: 5 



History: A Rooikat driver hit by a 
missile of unknown type. 

Mobility: Extricated through the 
emergency door and placed on a 
stretcher. 

Airway: Open 

Skin: Warm and normal 

Breathing Quality: Normal 

Breathing Rate: 22/min 

Pulse Quality: Normal 

Pulse Rate: 94/m in 

Blood Pressure: 120/70 mmHG 

Findings: Shrapnel wound to lower 

abdomen. 


Neurological Status: Disorientated and 
confused; opens eyes on voice; obeys 
commands; pupils equal and reacting to 
light. 


• Fluid Requirement: 2 Litre 

• Blood Requirement: 2 Units 

• Blood Group: A Pos 

• Theatre Time: 1 Hours 0 Min 


Patient No: 6 



DO 

+ 

o 

DO 


History: A bombardier with a 
shrapnel wound to left lower quadrant 
of the abdomen. 

Mobility: Removed from armoured 

vehicle and lying on a stretcher. 

Airway: Open 

Skin: Warm and normal 

Breathing Quality: Normal 

Breathing Rate: 18/min 

Pulse Quality: Normal 

Pulse Rate: 84/min 

Blood Pressure: 120/80 mmHG 

Findings: Shrapnel wound visible. No 

active bleeding. 

Neurological Status: Orientated; 
opens eyes spontaneously; obeys 
commands. 


• Fluid Requirement: 2 Litre 

• Blood Requirement: 0 Units 

• Blood Group: A Pos 

• Theatre Time: 1 Hours 0 Min 


Patient No: 7 



DO 

+ 

DO 


History: A 21 -year-old infantry soldier 
that was involved in an artillery shell 
explosion near his position. 

Mobility: Lying 
Airway: Compromised 
Skin: Cool, moist, ashen grey 
Breathing Quality: Rapid, deep, regular 
Breathing Rate: 22/min 
Pulse Quality: Rapid, strong, regular. 
Pulse Rate: 96/min 
Blood Pressure: 130/85 mmHG 
Findings: Open fracture to skull. 
Neurological Status: Making 
incomprehensible sounds; withdraw on 
pain and open eyes only on pain; pupils 
equal and reacting to light. 


• Fluid Requirement: 2 Litre 

• Blood Requirement: 0 Units 

• Blood Group: A Pos 

• Theatre Time: To be determined 


Patient 



™ Picture: http://timesonline.co.uk 

o 

DO 


No: 8 

• History: A 27-year-old corporal that 
was involved in a shelling incident with 
enemy forces. 

• Mobility: Sitting 

• Airway: Open 

• Skin: Warm, with burns to the chest 
and arms, all exposed areas keep on 
burning with smoke appearing from 
burning flesh 

• Breathing Quality: Normal 

• Breathing Rate: 18/m in 

• Pulse Quality: Rapid and full 

• Pulse Rate: 92/min 

• Blood Pressure: 120/80 mmHg 

• Findings: When lights are switched 
off, the burns glow in a greenish colour 
in the dark. 

• Neurological Status: Awake 


• Fluid Requirement: 2 Litre 

• Blood Requirement: 0 Units 

• Blood Group: B Pos 

• Theatre Time: 0 Hours 0 Min 



Patient 


Picture: httpJ/z.bp.blogspot.com 


No: 9 


• History: A Medic of a foot patrol involved in 
an IED explosion. 

• Mobility: Lying in a bundle in a groundsheet 
carried by the members of the foot patrol 

• Airway: Seriously compromised; gurgling. 

• Skin: Cold and moist 

• Breathing Quality: Shallow with gurgling 
noises 

• Breathing Rate: About 8/min 

• Pulse Quality: Weak; rapid; regular. 

• Pulse Rate: 128/min 

• Blood Pressure: 100/60 mmHG 

• Findings: Shrapnel wounds to abdomen, 
both legs and left arm. Several pieces of 
shrapnel penetrated the abdomen. Soldiers 
give information that IED contained 
numerous nails and nuts. 

• Neurological Status: Opens eyes only to 
painful stimuli; trying to talk; withdraw from 
painful stimuli, both pupils dilated. 


• Fluid Requirement: 4 Litre 

• Blood Requirement: 4 Units 

• Blood Group: O Pos 

• Theatre Time: 2 Hours 45 Min (Level 2) 



No: 10 


Patient 


• History: An 18-year-old Commander of a 
Rooikat armoured vehicle involved in a 
collision while travelling at high speed. 

• Mobility: Extricated and placed on stretcher 

• Airway: Compromised 

• Skin: Blue and cold 

• Breathing Quality: Fast, shallow and 
laboured 

• Breathing Rate: 28/min 

• Pulse Quality: Fast; rapid; regular 

• Pulse Rate: 144/min 

• Blood Pressure: 100/60 mmHG 

• Findings: Multiple chest and abdominal 
injuries; pneumothorax right; abdomen tender 
over upper right quadrant. 

• Neurological Status: Opens eyes to voice; 
inappropriate answers to questions; moves 
arms and legs on requests. 


• Fluid Requirement: 2 Litre 

• Blood Requirement: 3 Units 

• Blood Group: O Pos 

• Theatre Time: 1 Hours 45 Min (Level 2) 


SOUTH AFRICAN MILITARY HEALTH SERVICE 


MILMED Scientific: Operational Medicine 
CPD Answer Sheet No 1 

Demographics: 

Force Number: Rank: 

Initials and Surname: 

HPCSA/SANC Registration Number: 

Unit: 

Postal Address: 


Signature: 


Date: 


Answers: 


1 

A 

B 

C 

D 

E 

2 

A 

B 

C 

D 

E 

3 

A 

B 

C 

D 

E 

4 

A 

B 

C 

D 

E 

5 

A 

B 

C 

D 

E 

6 

A 

B 

C 

D 

E 

7 

A 

B 

C 

D 

E 

8 

A 

B 

C 

D 

E 

9 

A 

B 

C 

D 

E 

10 

A 

B 

C 

D 

E 


11 

A 

B 

C 

D 

E 

12 

A 

B 

C 

D 

E 

13 

A 

B 

C 

D 

E 

14 

A 

B 

C 

D 

E 

15 

A 

B 

C 

D 

E 

16 

A 

B 

C 

D 

E 

17 

A 

B 

C 

D 

E 

18 

A 

B 

C 

D 

E 

19 

A 

B 

C 

D 

E 

20 

A 

B 

C 

D 

E 



SOUTH AFRICAN MILITARY HEALTH SERVICE 


MILMED Scientific: Operational Medicine 
CPD Answer Sheet No 2 

Demographics: 

Force Number: Rank: 

Initials and Surname: 

HPCSA/SANC Registration Number: 

Unit: 

Postal Address: 


Signature: Date: 

Answers: Indicate the Triage priority for each patient, e.g. PI, P2, P3, P4, Dead 


Patient No 

Triage 

SIEVE 

Triage 

SORT 

1 



2 



3 



4 



5 




Patient No 

Triage 

SIEVE 

Triage 

SORT 

6 



7 



8 



9 



10 





BREATHING? 


YES 



NO 


OPEN 

AIRWAY 


PRIORITY 3 

MINOR 


DEAD 


NO 


BREATHING? 


YES 



9 or less 


30 or more 


PRIORITY 1 

CRITICAL 


10-29 



Under 120min 


(CRT < 2 Sec*) 

Capillary Refill Time (CRT) is an alternative to pulse rate, but is unreliable in 
the cold or dark: if it is used, a CRT of > 2 seconds indicates PRIORITY 1 


PRIORITY 2 

URGENT 


Used with permission from: Crisis Medicine Training Network 
© www.crisismedicine.co.za 












UTriage Level 1 and 2: Sort 


STEP 1 : Calculate the GLASGOW COMA SCORE (GCS) 


A: Eye opening: 

Spontaneous 

4 

To Voice 

3 

To Pain 

2 

None 

1 


B: Verbal 
response: 

Orientated 

5 

Confused 

4 

Inappropriate 

3 

Incomprehensible 

2 

No Response 

1 


C: Motor response: 

Follows command 

6 

Localise Pain 

5 

Withdrawal to pain 

4 

Flexion to pain 

3 

Extension to pain 

2 

No Response 

1 




Glasgow Coma Score (GCS) = A + B + C 


STEP 2: Calculate the TRIAGE SORT SCORE 


X: Convert 
Glasgow Coma 
Scale 


13-15 

4 

9-12 

3 

00 

1 

CD 

2 

4-5 

1 

3 

0 


Y: Respiratory 
Rate 

10-29 

4 

>29 

3 

6-9 

2 

1-5 

1 

0 

0 


Z: Systolic Blood 

Pressure 


>90 

4 

76-89 

3 f 

50-75 

2 ! 

1 -49 

1 

0 

0 


►STEP 3: Assign a triage PRIORITY 

12 

Priority 3 - Minor 

11 

Priority 2 - Serious 

<10 


0 

Dead 

STEP 4: Upgrade PRIORITY, dependent on the injury/ 
diagnosis 


© With permission from: Crisis Medicine Training Network www.crisismedicine.co.za 




Stepped-Up Health Support Concept 

Combat Zone Communication Base Zone 


Inherent 


Landward Defen 


Combat Life Saver 


Buddy Aid 


Operational Health 


Zone 


Emergency Care 
Section 


Land Based 
Emergency Care 


Level 1 Forensic 


Level 1 Capability 
Land Mobile 
Level 1 Capability 
Air Landed 

Level 1 Capability 
Sea Landed 

Level 1 Capability 
Air Droppable 





Level 2 
Field Hospital 


In Theatre 



lulti Professional Team 


Poly Clinic 


Unit Sickbay / MMC 


Level 1 


Ship Capability 


Level 2 


Hospital 

Ship 


Military Base 
Hospital 


Force Prep 
Emergency Care 


Casualty Receiving 


Air Crash 
Response Team 


Buddy Aid 


Local Capability 


First Aid 


Buddy Aid 


Shore Capability 


Local Capability ] 

I 


Prov Health 
Facility 


Prov Health 
Facility 


Level 3 

Specialist Hosp 


Military Hospital 


Level 2 
Field Hospital 


Level 2 Forensic 


Level 4 
Base Hospital 

k A 


Civilian 

Health 

Facilities 


Dept of Health 
Forensic 
Capability 


Prov Health 
Facility 

© Col T. Ligthelm 












Mech Div 


Military Health Landward Defence Support Doctrine 



Special 

Forces 


Total Contin Bde: 
±8 X Task Groups 
3-6 X Level 1 


© Col T. Ligthelm 
10/2009 


SHIAIVS 






















SA NAVY 



LPH 
Capability 


Contin Bde 


Special 

Forces 


Military Health Maritime Defence Support Doctrine 


Total Maritime Defence Estimates 
37 X Medical Sections 
12 X Medical Task Tms 
5 X Task Gps 


Spes Med 
Task Gp 


Spes Med 
Bn Gp 


fe)i 


Total Contin Bde: 
±6 X Task Groups 
3-6 X Level 1 


© 


Col T. Ligthelm 
10/2009 


1 Mil Hosp 


IMM 


2 Mil Hosp 

0 


SHIAIVS 

















SA AIR FORCE 


Military Health Air Defence Support Doctrine 



Contin Bde 


Special 

Forces 


Total Contin Bde: 
±6 X Task Groups 
3-6 X Level 1 


© Col T. Ligthelm 
10/2009 


SHIAIVS